ADHD Referral Request

Please state the reason for requesting a referral for ADHD: *

What are your expectations of this referral? *

Symptoms of ADHD tend to be noticed at an early age and may become more noticeable when a child's circumstances change, such as when they start school. Did you experience any problems during your early childhood at home and within the school environment? Your main care takers may be to help with this information. Please provide any school reports/assessments that you have. *

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

Yes

No

Please provide details: *

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.

Inattentiveness:

Hyperactivity and impulsiveness:

Do you have any sleep problems? *

Yes

No

Please provide details: *

Have you suffered from mental health problems such as depression and anxiety or any other mental health problems? *

Yes

No

Please give details of diagnosis and treatment plan including medication and psychological therapies: *

Have you been diagnosed with any learning difficulties (e.g. dyslexia)? *

Yes

No

Please provide details: *

Have you been diagnosed with any neurodevelopmental disorders (Tourette's syndrome, epilepsy, autistic spectrum disorder (ASD), dyspraxia, head injury)? *

Yes

No

Please provide details: *

Do you have any physical health problems? *

Yes

No

Please provide details of the diagnosis and treatment plan: *

Do you have any past or present history of misusing alcohol or illicit substances? *

Yes

No

Please provide details: *

Do you have any past or present forensic history, including driving offences? *

Yes

No

Please provide details: *

Please upload any relevant documentation:

Maximum upload size: 67.11MB

*

I confirm that the information provided is accurate to the best of my knowledge

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