ADHD/Autism Referral

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:

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 upload size: 67.11MB

Consent

Confirmation

I consent to referral under Right to Choose/NHS services

I confirm this information is accurate

Signature

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Date:

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Section

Reason for referral

Core symptoms

Childhood history

Mental health & other conditions

Medication screening

RTC Provider

Consent