ADHD patient referral part two form

This form needs to be completed by the patient, family member or carer.

For any questions that require an answer but are not applicable to you, please state N/A.

Completed by

Please state if you are the patient, family member or carer. If the family member or carer please also state your name.

Are you the patient, family member or carer? Required

Patient

Family member

Carer

Please state your name if you are the family member or carer

Patient details

Patient name Required

Date of birth Required

NHS number Required

Primary address Required

Correspondence address Required

Next of kin details Required

Parental responsibility Required

Children in household. Include name and date of birth Required

Background information

Why are you seeking assessment for ADHD at this time? Required

What would a diagnosis of ADHD mean for you? Required

Main problems

What are your main problems? i.e. inattention, hyper-activity, impulsivity Required

What is the impact of the problems on these areas of your life?

Education/ employment Required

Personal/ social relationships Required

Social interaction and communication difficulties Required

Self-concept/ view of self Required

Risks associated with offending behaviour Required

Childhood symptoms of ADHD (before the age of 12)

Impact on school/ learning problems Required

Impact on family/ parental/ friendships Required

Risk taking/ accidents (frequent A&E attendance, dangerous situations) Required

Impulsivity/ consequence of actions Required

General behaviour Required

Developmental history – did you have any of the following?

If ticked yes to any, please describe the problem and any investigations and treatment.

Any developmental diagnoses? i.e. autism, specific learning difficulty, learning disability etc. Required

Any childhood adverse events? i.e. trauma, abuse, parental mental health problems, parental substance abuse/ safeguarding needs Required

Family history

Any known family history of ADHD? Please give details of familial relationship and diagnosis Required

Any known family history of autism, specific learning difficulty, learning disability, dyslexia, dyspraxia, dyscalculia, anxiety, depression, OCD, Tourette’s, psychosis, alcohol/substance use problem, genetic disorder, cardiovascular problems? Required

Educational/work history

Currently in education? Required

School/college

Higher education

Mainstream or other schools attended? (include primary and secondary) Required

Any SENCO/ Educational Healthcare Plans (EHPs)? Required

Problems encountered during school day? (breaktimes, detentions) Required

Academic results (GCSEs) Required

Are school reports available? Required

Yes

Employment

Currently working? Required

Employed

Self-employed

Not working

What is your job?

How long in current role?

Please give details of any problems in work/ employment with 1. peers/colleagues, 2. managers, 3. time management Required

Drug and alcohol history

Current weekly alcohol intake (units per week, on average) Required

Current cannabis use (on average per week) Required

Use of other recreational substances, in particular stimulant drugs (e.g. cocaine, amphetamines, MDMA etc) Please breakdown 1. effect, 2. current usage, 3. past usage Required

Current caffeine intake (coffee, energy drinks etc) Required

Current nicotine intake (cigarettes and/or vaping)? Required

Sleep history (describe your sleeping pattern) Required

Eating/ appetite history (describe any disordered eating) Required

Risk assessment

Attempted suicide with genuine intent Required

If yes, give details.

Had any thoughts about ending your life? Required

If yes, please give details

Intentionally harmed yourself? Required

If yes, please give details

Experienced self-neglect Required

If yes, please give details

Used alcohol/substances in a harmful way Required

If yes, please give details

Evidence of risk of harm from others

Child Protection Plan (CPP) indicator (social services involvement):

As a child were you subject to a CPP? Required

If yes, please provide details

Victim of domestic abuse

Please give details if selected disclosed

Risk of abuse

Emotional/psychological (including bullying)

Financial

Physical

Unlawful restrictions

Sexual (unwanted, non-consensual)

Please give any further details

Evidence of risk from physical health

Select if applicable

Mobility - difficulty accessing areas/getting up stairs

Epilepsy

Choking – due to self-harm, cramming mouth with food, Pica, difficulties swallowing

Provide any further details

Evidence of other risk behaviours

Absconding/escape

Provide any further details

Evidence of risk of accidents

Select if applicable

Accidental harm outside the home (e.g. wandering)

Driving/road safety

Falls - to the point of where you cause physical harm

Fire

Unsafe use of medication (e.g. accidental double dosing. If yes, explore what happened and when)

Provide further details

Adult ADHD self-report scale symptom checklist

Please answer the question below, rating yourself on each of the criteria shown. As you read each question, answer them based on how you have felt and conducted yourself over the past six months.

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

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

Never

Rarely

Sometimes

Often

Very often

How often do you have problems remembering appointments or obligations? Required

Never

Rarely

Sometimes

Often

Very Often

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

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

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

Never

Rarely

Sometimes

Often

Very often

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

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

Never

Rarely

Sometimes

Often

Very often

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

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

Never

Rarely

Sometimes

Often

Very often

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

Never

Rarely

Sometimes

Often

Very often

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

How often do you feel restless or fidgety? Required

Never

Rarely

Sometimes

Often

Very often

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

Never

Rarely

Sometimes

Often

Very often

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

Never

Rarely

Sometimes

Often

Very often

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 them themselves? Required

Never

Rarely

Sometimes

Often

Very often

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

Never

Rarely

Sometimes

Often

Very often

How often do you interrupt others when they are busy? Required

Never

Rarely

Sometimes

Often

Very often

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