ADHD Referral Form

Step 1 of 3

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Name(Required)

First name

Surname

Date of Birth(Required)

DD dash MM dash YYYY

Gender(Required)

Male

Female

Transgender

Non-binary

Other

Is your current gender the same as at birth?(Required)

Yes

What was your gender at birth?

Male

Female

If Other, please specify:

Telephone(Required)

What are the best ways to communicate with you or to send you information?(Required)

Phone

Post

Interpreter required?(Required)

Yes

What language?(Required)

What is your currently employment status?(Required)

Full-time employment

Part-time employment

Self-employed

Looking for work

Unemployed

Retired

Student

Prefer not to say

Type of Accomodation(Required)

Lives alone

Lives with partner(s)

Lives with parent(s)

Lives with other relative(s)

Lives with friend(s)

Student residency

Homeless

Other

Prefer not to say

Please provide the details of someone who could provide an observer’s report or collateral history of your symptoms – preferably someone that has known you since childhood, such as your parents or siblings.

Please kindly inform them that the ADHD clinic will be contacting them.

Please note: the ADHD clinic will not accept any referral without these details being provided.

Name(Required)

First name

Surname

Telephone(Required)

Their relationship to you:(Required)

Primary and secondary school reports attached?(Required)

Yes

File

Max. file size: 300 MB.

Please be aware that lack of these reports might delay your assessment.

Please list or explain current issues and why these issues could be possibly related to ADHD (i.e. presenting problem, history of symptoms). Provide as much information as possible(Required)

Please state how the above symptoms were present in childhood (under 12 years)(Required)

Symptoms Checklist (Adult ADHD Self-Report Scale – ASRS)

This section is mandatory. Any referrals submitted with the following page incomplete will be returned for completion.

The following screening must be completed by the patient.

Check the box that best describes how you have felt and conducted yourself over the past 6 months.

1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?(Required)

Never

Rarely

Sometimes

Often

Very Often

2. How often do you have difficulty getting things in order when you have to do a task that requires organization?(Required)

Never

Rarely

Sometimes

Often

Very Often

3. How often do you have problems remembering appointments or obligations?(Required)

Never

Rarely

Sometimes

Often

Very Often

4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?(Required)

Never

Rarely

Sometimes

Often

Very Often

5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?(Required)

Never

Rarely

Sometimes

Often

Very Often

6. How often do you feel overly active and compelled to do things, like you were driven by a motor?(Required)

Never

Rarely

Sometimes

Often

Very Often

7. How often do you make careless mistakes when you have to work on a boring or difficult project?(Required)

Never

Rarely

Sometimes

Often

Very Often

8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?(Required)

Never

Rarely

Sometimes

Often

Very Often

9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?(Required)

Never

Rarely

Sometimes

Often

Very Often

10. How often do you misplace or have difficulty finding things at home or at work?(Required)

Never

Rarely

Sometimes

Often

Very Often

11. How often are you distracted by activity or noise around you?(Required)

Never

Rarely

Sometimes

Often

Very Often

12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?(Required)

Never

Rarely

Sometimes

Often

Very Often

13. How often do you feel restless or fidgety?(Required)

Never

Rarely

Sometimes

Often

Very Often

14. How often do you have difficulty unwinding and relaxing when you have time to yourself?(Required)

Never

Rarely

Sometimes

Often

Very Often

15. How often do you find yourself talking too much when you are in social situations?(Required)

Never

Rarely

Sometimes

Often

Very Often

16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?(Required)

Never

Rarely

Sometimes

Often

Very Often

17. How often do you have difficulty waiting your turn in situations when turn taking is required?(Required)

Never

Rarely

Sometimes

Often

Very Often

18. How often do you interrupt others when they are busy?(Required)

Never

Rarely

Sometimes

Often

Very Often

Please use this space to record any additional information which you feel may be relevant:

Disclaimer

The information you provide in this form will be processed by Cedar Practice. The information will be treated as confidential and stored in a secure data centre located in the UK. The information will be uploaded to your record in the practice’s clinical system as soon as possible after submission, after which the copy of your information in the data centre will be securely destroyed.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of providing this information.

The information you provide will be processed with the sole purpose of providing you with Direct Care within the surgery and in support of Direct Care elsewhere. Our Privacy Policy provides further detail about how we process your personal information for the purposes of Direct Care.

You have the right to revoke this Consent to the terms laid here, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent.

Consent(Required)

I confirm I have read and agree to the above terms.

Consent(Required)

I acknowledge that the information I have provided is true and accurate, to the best of my knowledge.(Required)

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Phone

This field is for validation purposes and should be left unchanged.