ADHD/Autism Referral

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In order to proceed with an ADHD or Autism referral, please provide us with the below information:

Personal Details

Please double check you've entered the correct email address

UK mobile only

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Referral Questions

Reason for referral: *

Do you have any communication needs arising from a disability?: *

Do you require communication support?: *

Do you require a specific contact method?: *

Do you require information in a specific format?: *

Do you have any long term health conditions?: *

Do you have mobility issues?: *

Virtual appointments

To ensure patient safety, the service is offering virtual appointments (via secure and confidential video call) where possible and if clinically appropriate providing the same quality of care.

Are you happy to consult remotely?: *

Have you had a previous diagnosis of ADHD or Autism?: *

Do you have any psychiatric history (please include any details of interaction with Mental Health teams or hospital admissions): *

Do you have any children?: *

Are you on any treatment for your mental or physical health: *

Are you currently under a local mental health team (i.e. CMHT, IAPT or LD)?: *

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ADHD Questionnaire

Part A

1. How often do you make careless mistakes when you have to work on a boring or difficult project?: *

2. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?: *

3. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?: *

4. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?: *

5. How often do you have difficulty getting things in order when you have to do a task that required organisation?: *

6. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?: *

7. How often do you misplace or have difficulty finding things at home or at work?: *

8. How often are you distracted by activity or noise surrounding you?: *

9. How often do you have problems remembering appointments or obligations?: *

Part A Total Score:

Part B

10. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?: *

11. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?: *

12. How often do you feel restless or fidgety?: *

13. How often do you have difficulty unwinding and relaxing when you have time to yourself?: *

14. How often do you feel overly active and compelled to do things, like you were driven by a motor?: *

15. How often do you find yourself talking too much when you are in social situations?: *

16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish the sentence themselves?: *

17. How often do you have difficulty waiting your turn in situations when turn taking is required?: *

18. How often do you interrupt others when they are busy?: *

Part B Total Score:

ADI-R Informant

Before we book your assessment, it is helpful if we can complete a clinical interview Autism Diagnostic Interview-Revised (ADI-R) with someone who has known you well since childhood. This might be a parent, carer or a brother or sister. If you do not know anyone that could complete this clinical interview, please let us know by ticking the appropriate box. You will receive a copy of this assessment in your report from us.

The telephone interview will be booked in with your nominated person when you return the form. The telephone interview usually lasts 2-3 hours, and will cover your development since childhood.

Do you have a nominated informant?: *

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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ADHD/Autism Referral

Part A

Part A Total Score:

Part B

Part B Total Score:

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