ADHD Referral Request

Thank you for taking your time to complete this form. The information will be used to complete your ADHD referral request.

Please be advised that the current waiting time for an ADHD assessment is two and a half years once the referral has been accepted.

ADHD Referral Request

Are there any members of your family that have been diagnosed with ADHD? *

The symptoms of attention deficit hyperactivity disorder (ADHD) can be categorised into 2 types of behavioural problems:

  • Inattentiveness (difficulty concentrating and focusing) - e.g. short attention span, constantly changing activities or tasks, difficulty organising tasks, appearing forgetful and losing things, making careless mistakes, being unable to stick to tasks that are tedious or time-consuming.
  • Hyperactivity and impulsiveness - e.g. acting without thinking, being unable to sit still, excessive talking, little or no sense of danger, being unable to concentrate on tasks.

Please give a detailed account of when you have presented with these symptoms or similar and how this has impacted your daily life.

Do you have any sleep problems? *
Have you suffered from mental health problems such as depression and anxiety or any other mental health problems? *
Have you been diagnosed with any learning difficulties (e.g. dyslexia)? *
Have you been diagnosed with any neurodevelopmental disorders (Tourette's syndrome, epilepsy, autistic spectrum disorder (ASD), dyspraxia, head injury)? *
Do you have any physical health problems? *
Do you have any past or present history of misusing alcohol or illicit substances? *
Do you have any past or present forensic history, including driving offences? *
Please upload any relevant documentation:
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