Request referral for ADHD Assessment

This form has been sent because we need more information to see if you/your child possibly have ADHD. There are quite a few questions, so please make sure you have enough time to complete it. You can press the 'Save' button at the bottom of the form at any time.

Important: Please read carefully as the next steps may be delayed if the correct option is not chosen.

ADHD is a problem with attention and/or hyperactivity, to the point where it affects daily life. It usually starts in childhood. Key features of attention problems include very poor concentration, an inability to finish tasks and finding it hard to prioritise/organise things. There may also be features of being hyperactive or impulsive, such as fidgeting, interrupting people and not being able to wait your turn.

Important: Important Information

More information on the request for right to choose referral for ADHD assessment.
It is important to read this before completing the assessment forms as you will need to specify your chosen provider in the form.

Important: Important Information

If you think you might have Autism as well please remember to complete the Autism Assessment form after you have completed the ADHD assessment form below.

Request referral for ADHD Assessment

Based on what is written here, do you think you might have:

If you have selected 'ADHD and AUTISM' please remember to also complete the 'Request for Autism assessment' form as well.

Only specialists can make a diagnosis of ADHD. If the information you provide suggests this might be the case, would you like to be referred to a specialist for further assessment?

Before we start, do you have a diagnosis of a learning disability?

Details of the person this form is about.

Forename

Surname

Date of Birth

Post code

Contact telephone number (Mobile preferred)

Email address

If you are filling in this form on behalf of someone else, please give your name, relationship and contact number.

Do you have a social worker?

Have you ever been under the care of a mental health (psychiatry) team?

ADHD Treatment Medical Screening

Some of the treatments used for ADHD can affect the heart. Please tell us whether any of the following apply to you. Please answer to the best of your knowledge.

A history of sudden death under the age of 40 in a parent or sibling, which is thought to be a heart problem

Chest pain which is thought to come from your heart.

More shortness of breath on exertion, in comparison to your peers.

A history of congenital heart disease (a heart problem that you were born with) or heart surgery

Palpitations that are rapid, regular and stop suddenly (not fleeting or occasional 'bumps').

Known to have high blood pressure.

Fainting on exertion, or in response to fright or noise.

Known to have a heart murmur.

A diagnosis of heart failure.

There are three main features of ADHD:

Inattention (lack of concentration)

Hyperactivity (fidgeting, excessive talking, unable to wait)

Impulsivity (doing things rapidly without thinking them through).

We need to gather more about them and their effect on you.

The more detail you can give, the better.

Please describe your problems with attentions, hyperactivity and, or impulsivity (doing thing without thinking them through first).

When did you first notice your ADHD symptoms (approximate age)?

We also need you to complete the following. The referral cannot be sent without it, unless it is for a child under the age of 12.

Rate yourself on each of the criteria shown. As you answer each question, select the option that best describes how you have felt and conducted yourself in the past 6 months.

Part A

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

How often do you have difficulty getting things in order when you have to do a task that requires organisation?

How often do you have problems remembering appointments of obligations?

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

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

How often do you feel overly active and compelled to do things, like you were driven by a motor?

Part B

How often do you make careless mistakes when you have to work on a boring or difficult project?

How often do you have difficulty keeping your attention when you are doing boring or repetitive work?

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

How often do you misplace or have difficulty finding things at home or at work or school?

How often are you distracted by activity or noise around you?

How often do you leave your seat in meetings or other situations in which you are expected to remain seated?

How often do you feel restless or fidgety?

How often do you have difficulty unwinding and relaxing when you have time to yourself?

How often do you find yourself talking too much when you are in social situations?

When you are in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish themselves?

How often do you have difficulty waiting your turn in situations when turn taking is required?

How often do you interrupt others when they are busy?

If we need to do a referral to a specialist, they want to know the following information about your thought regarding the referral. Please give as much information as possible they may refuse the referral otherwise.

Please describe how these difficulties have affected your education, work and relationships

What are your concerns?

What do you expect or hope to gain from a specialist assessment?

Where would you like to be referred to?

Thank you for the information. We will get back to you as soon as we can.

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