Thank you for taking the time to complete this questionnaire, it helps the team to prepare for your appointment and this information is strictly private and confidential. If you need any assistance completing or require any help filling in this form please contact the assessment centre on 0191 2875090. 

The theory test support sessions will take place at Walkergate Park Hospital, Benfield Road, Newcastle upon Tyne and are charged at: 

First session  £20 

One to one £40 per session 

Private and Confidential

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Address: Required
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I prefer to be contacted by: Required
I would prefer (tick all that apply):  Required

About your general health/Medical condition(s) and Vision

Have you or are you experiencing any of the following? (Please tick all of which apply to you)
Do you have any problems with your mobility? Required

About your license

Your license status: Required
Please tick any of the following that best applies to you: Required
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Consent Form

Please read the following sentences and tick if you agree to them:

I understand the information I have been given, and I agree to be assessed 

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Service monitoring

As part of our aim to reach everyone in the community, we would be grateful if you would complete these questions on the final page of this questionnaire.  Please tick one of the following for monitoring purposes. 

White
Mixed
Asian or Asian British
Black or Black British
Chinese or other ethnic group
I do not wish to respond to the above information

If you decide/chose not to attend for a driving assessment you must contact the Centre as soon as possible, this is so we can re-allocate an appointment for a client that is/will be waiting for an appointment. 

This completed form should be returned in the pre-addressed envelope provided and or with any further information included (a stamp/postage is required by yourselves and is not provided with the envelope).  If you are completing this form by email (downloaded version) please copy and scan any further information you desire/additional information along with this application form to this email address IndependentTravel@cntw.nhs.uk

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