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Brookside Group Practice Partners in Healthcare

ADHD/Autism Referral

Can you confirm that you have read and meet the criteria for an ADHD/Autism referral? *

Yes

No

You need to meet the criteria for an ADHD/Autism referral in order to complete this review. If you have any queries, please contact the practice on Brookside Surgery 0118 966 9333 or Chalfont Surgery or Winnersh Surgery or Wilderness Road Surgery .

Section

Reason for referral

In your own words, why are you seeking an ADHD and/or autism assessment?

Please describe your main difficulties and how long they’ve been present: *

Core symptoms

Please tick all those that apply and provide examples.

ADHD symptoms:

Easily distracted

Difficulty sustaining attention

Frequently loses things

Disorganised

Avoids tasks requiring focus

Distracted by noise or activity

Please give examples: *

Hyperactivity/impulsivity:

Fidgety/squirming

Leaving a seat in meetings/whilst in session

Feeling restless/driven by a motor

Difficulty relaxing

Talking excessively/interrupting

Please give examples: *

Autism traits:

Difficulty with social communication

Struggles with change/routine

Sensory sensitivities

Intense interests

Please give examples: *

Childhood history

Did you have these traits as a child?

Yes

No

Examples from school/home:

Any school reports or concerns?

Yes

No

Diagnosed with learning difficulties?

Yes

No

Mental health & other conditions

Any diagnosed mental health conditions?

Any current symptoms (anxiety, depression, trauma, etc.)?

Would you feel as though you would benefit more from a mental health service?

Do you feel another condition better explains your symptoms?

Please confirm: *

I do not have a diagnosis of moderate/severe learning disability

My needs are not primarily due to a severe/enduring mental illness

I understand ADHD medication may be part of treatment

Medication screening

Please list any current medications:

Do you have any heart conditions?

Yes

No

Please give details: *

Have you ever had palpitations, fainting, or chest pain?

Yes

No

Please give details: *

Do you have high blood pressure?

Yes

No

Please give details: *

Difficulty falling or staying asleep?

Yes

No

Please give details: *

Any current drug or alcohol problems?

Yes

No

Please give details: *

Any family history of cardiovascular disease?

Yes

No

Please give details: *

Any history of psychosis or bipolar disorder?

Yes

No

Please give details: *

Height:

In metres

Weight:

In KG

RTC Provider

Please visit ADHD UK: Right to choose

Please confirm your preferred provider:

Please attach the following (if available):

Any school reports
Previous assessments
Employer letters
Family observations
ASRS checklist

Upload a file:

Maximum file size: 67.11MB

Consent

Confirmation *

I consent to referral under Right to Choose/NHS services

I confirm this information is accurate

Signature *

Please enter full name

Date:

If you are human, leave this field blank.

Brookside Surgery
Brookside Close
Earley
Berkshire
RG6 7HG

Get directions

0118 966 9333

Chalfont Surgery
Chalfont Close
Lower Earley
Reading
RG6 5HZ

Get directions

Winnersh Surgery
10 Melbourne Avenue
Winnersh
RG41 5EL

Get directions

Wilderness Road Surgery
1 Wilderness Road
Earley
Reading
RG6 7RU

Register with the surgery

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