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Part-Funded by the Welsh Assembly Government
Online Application - North Wales

  1. Assessment Application Form

  2. Title(*)
    Please select a Title.
  3. Full Name(*)
    Please let us know your name.
  4. Date of Birth(*)
    Please enter your Date of Birth.
  5. Contact Telephone Number(*)
    Please enter a number we can contact you on.
  6. Mobile
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  7. Your Email
    Please let us know your email address.
  8. Address Line 1(*)
    First line of your address
  9. Address Line 2(*)
    Second line of your address
  10. Address Line 3
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  11. Address Line 4
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  12. Post Code(*)
    Enter your Post Code here
  13.  

  1. Section A – About You


  2. If you know the name of your medical condition or disability (e.g. cerebral palsy), please write this here. If you have a non-specific medical condition or disability, please give as much information as you can, (e.g. back problems or problems with concentration).

  3. What kind of medical condition or disability do you have?(*)
    Please give as much information about your disability as you can

  4. Please give as much information as possible. For example, are your limbs affected by restricted movement or lack of strength? Do you easily get tired or have problems with coordination, etc?

  5. Please describe how your medical condition affects you.(*)
    Please enter some information about how your disability affects you.

  6. How long have you had this medical condition or disability?(*)
    Please tell us how long you have had a disability.
  7. Can you walk at all?
    (*)


    Please select either Yes or No to this question.
  8. Do you ever use a wheelchair/scooter?(*)


    Please select either Yes or No to this question.
  9. Do you ever use a wheelchair/scooter at home?


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  10. Do you ever use a wheelchair/scooter outside?


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  11. If you use a wheelchair, can you transfer into a vehicle without help from others?


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  12. Are you in receipt of the Higher Rate Mobility Component of the Disability Living Allowance?(*)


    Please select either Yes or No to this question.
  13. or the Mobility Supplement of the War Pension?(*)


    Please select either Yes or No to this question.
  14.  

  1. Section B – Your Assessment

  2. Our Centres offer five assessment and advice services. The information below will help you decide which of these is best for you. They each vary in how long they take and a different fee is charged for each service. A full report is prepared after each service.



    a) Driving Ability Assessment. If you have or have had a full licence, this assessment looks at both your ability to control the vehicle and to deal with traffic and other road users. It is for people such as those who have had illness or injury. It is advisable to bring another driver to accompany you on the day of the assessment.

    b) Driving Ability Assessment (Learner driver with Provisional licence). This assessment is for people who are concerned about beginning to learn to drive, who are experiencing problems with driving tuition or who have learning difficulties.

    c) Specialist Vehicle Assessment for drivers. This assessment is for people who need high technology solutions, for instance those who need to drive from a wheelchair. This type of assessment will be suitable if you cannot transfer from your wheelchair or if you cannot stow your wheelchair on your own. We will give you the opportunity to try out equipment in an adapted Chrysler Voyager. Please note that cars can also be fitted with high technology equipment. To undertake this type of assessment you will require a valid driving licence, which can be either: Full, Provisional, or a Provisional Disability Assessment Licence. The assessment looks at both your ability to control the vehicle and to deal with traffic and other road users.

    d) Passenger/Carer Assessment. This service is for passengers who have difficulty getting in and out of a vehicle. The assessment explores a range of options including the use of specialist transfer equipment and wheelchair accessible vehicles. This service may also benefit carers who are experiencing difficulty assisting in the transfer of their clients.

  3. Tick the box that mainly describes your requirements. If you are unsure of the type of assessment you wish to apply for, please contact the Assessment Service for assistance.
  4. What type of assessment do you want to apply for?(*)





    Please select the assessment type you want to apply for.
  5. If you are unsure which assessment you require, please contact the Assessment Centre.
  6.  

  1. Please enter below any dates over the next four months when you cannot attend for an assessment.
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  2. Occasionally people cancel appointments at short notice. Would you like us to contact you if a cancellation occurs and it would mean an earlier appointment?(*)


    Please select either Yes or No to this question.

  3. Do you have any other special requirements during your visit?
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  4. If English is not your first language will you require the services of an interpreter?


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  6.  
  1. If you require an assessment as a driver, please go to Section C

    If you require an assessment as a passenger, please go to Section D

  2. Section C – Driving Licence Details

  3. Do you have a valid driving licence?
    (Licence must be shown at time of assessment)






    Please tell us what type of license you currently hold.
  4. Tick the box that mainly describes your requirements
  5. Please give the following details about your driving licence
  6. Driving Licence Number
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  7. Licence valid from / to
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  8. What type of vehicle do you drive at present?


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  9. Does the DVLA know about your present condition or disability?


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  11. Has a doctor advised you against driving?(*)


    Please let us know if you have been advised against driving by your doctor or other medical professional.
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  13.  

  1. Section D - Payment

  2. We charge a subsidised fee for assessments. The costs for the assessments are:

    a) Driving Ability Assessment £95
    b) Passenger Assessment £95

    We can accept cheques and postal orders, if you prefer to pay by Credit/Debit Card this method is acceptable but you will have to telephone this centre with your card details when your Application Form is processed to enable your assessment appointment to be processed.

    Cheques should be made payable to: Wales Mobility and Driving Assessment Service.

    Payments will not be refunded if assessment is not attended or cancelled within 48 hours of appointment date.

  3. I agree to the above
  4.  

  1. Section E

  2. To help us plan our services, could you tell us how you heard about the Assessment Service?
















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  3. As part of our aim to reach everyone in the community, it would help us if you could tick one of these boxes for monitoring purposes.






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  1. Thank you for taking the time to complete this application form.