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ADHD assessment request

ADHD assessment request

Are you willing to attend appointments and actively engage in the assessment process?
Have you been having suicidal thoughts or making plans to harm yourself?

Call 999 or go to A&E now if:

  • someone’s life is at risk – for example they have seriously injured themselves or taken an overdose
  • you do not feel you can keep yourself or someone else safe

A mental health emergency should be taken as seriously as a physical one. You will not be wasting anyone’s time.

Call: 999

Find your nearest A&E

Are you using illegal / non-prescription drugs because of your symptoms?
Are you willing to take life-long medication if you are given a diagnosis of ADHD?
Do you think you may also have Autism, but do not yet have a diagnosis?
Are you already receiving treatment from NHS mental health services?
Do you need an interpreter (sign-language or foreign language)?
Do you require reasonable adjustments?
Please select all that apply.
Is there any family history of ADHD or Autism?
Would you be willing to take life-long medication if diagnosed with ADHD?
Please note – if you do not wish to take medication, do not complete this form. Instead, ask your GP to refer you to the locally commissioned ADHD service, as they are able to provide non-pharmaceutical treatment.
Do you think you have any of the following conditions (it doesn’t matter if you do not have a formal diagnosis):
Did you experience any difficulties or challenges during your education, including preschool, primary school, secondary school, or higher education?
What is your education / employment status?
Please select all that apply.
Are you currently experiencing any difficulties or challenges at college or higher education?
Have you experienced any difficulties at work, such as with attendance, workplace relationships, or staying in employment?
What is your relationship status?
Do you have any children?
Do you experience relationship difficulties with your partner, children, extended family, friends, or others?
Have you had any of the following:
Do you have impulsive behaviours relating to relationships, drugs, alcohol, or finances?
Do you participate in risk taking behaviour / self-harm / self-neglect?
Do you have any current suicidal ideation?

Call 999 or go to A&E now if:

  • someone’s life is at risk – for example they have seriously injured themselves or taken an overdose
  • you do not feel you can keep yourself or someone else safe

A mental health emergency should be taken as seriously as a physical one. You will not be wasting anyone’s time.

Call: 999

Find your nearest A&E

Do the traits that you believe are ADHD negatively impact your life in a way that has not already been captured by the questions above?

Part A of the ASRS questionnaire

For each question, please select one answer that best describes how often this applies to you.
Do you have trouble completing the final details of a piece of work once the challenging parts have been finished?
Do you have difficulty getting things in the right order when you do a task that requires organisation?
Do you have problems remembering appointments or obligations?
When you have a task that requires a lot of thought do you avoid or delay getting started?
Do you fidget or squirm with your hands or feet when you have to sit down for a long time?
Do you feel overly active and compelled to do things, like you were driven by a motor?

Part B of the ASRS questionnaire

For each question, please select one answer that best describes how often this applies to you.
Do you make careless mistakes when you have to work on something boring or difficult?
Do you have difficulty keeping your attention when you are doing boring or repetitive work?
Do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
Do you misplace or have difficulty finding things at home or at work?
How often are you distracted by activity or noise around you?
Do you leave your seat in meetings or other situations in which you are expected to remain seated?
How often do you feel restless or fidgety?
Do you have difficulty unwinding and relaxing when you have time to yourself?
Do you find yourself talking too much when you are in social situations?
When you’re in a conversation, do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
Do you have difficulty waiting your turn in situations when turn taking is required?
Do you interrupt others when they are busy?

Right to Choose

There are numerous ADHD Right to Choose providers who can undertake ADHD assessments. However, there are concerns in relation to the quality of assessments being undertaken by some providers and not all providers are able to offer all aspects of the ADHD pathway. Specifically, some of the providers are unable to issue NHS prescriptions for medication or support annual treatment reviews, which can result in patients having to pay private prescription fees for medication, which cannot be recovered from the NHS.

To ensure the quality and completeness of service delivered to patients Staffordshire and Stoke ICB have reviewed the most frequently requested ADHD Right to Choose providers. The providers listed below have demonstrated that they are able to provide a quality service for patients and deliver all aspects of the ADHD pathway. If you wish to be referred to a Right to Choose provider who does not appear on this list please ask your GP to make enquiries with the ICB Commissioners, so that checks can be made to ensure they are able to deliver the whole of the ADHD pathway.

There are also some instances in which a Right to Choose provider cannot meet the needs of a patient who requires an ADHD assessment. If the information provided suggests that this applies to you, a referral will be made to the local mental health service instead.

If you have a preferred provider, please select one of the boxes below. Please note that if you are approved for an assessment and you have not nominated a provider or you have selected more than one box, you will be referred to the local mental health provider for an assessment.

Preferred provider:

Patient declaration

By signing this application, I confirm that:

  • I believe the information above to be a true and accurate reflection of my history and current circumstances
  • I consent to my information being shared with MLCSU to assess whether the impairment I am experiencing due to ADHD traits meets the threshold for an NHS funded ADHD assessment
  • I understand that my GP will be informed of the outcome of this request and that I will receive a copy of the outcome letter by email to the address that I have provided.

If the application is approved:

  • I understand that I will be referred to the provider that I have chosen unless they are not clinically appropriate to undertake my assessment.
  • I understand that if my chosen provider is not appropriate to undertake my assessment I will be referred to an alternate provider who is able to meet my needs.
  • I agree to the information provided by my GP, on this form and on the form completed by my associate, being shared with the approved provider.
  • I agree to the provider contacting me by email.
  • I agree to engage fully in the assessment process
  • I agree to attend all notified appointments
  • I agree to try ADHD medication if this is offered to me as a treatment option
Terms and conditions

Questions about the patient

To be completed by the patient’s associate

You have been asked to complete this form to provide insight into the behaviours of the person named above. The information you provide will be used, in conjunction with information provided by the patient and their GP to review how their life is currently impaired by symptoms often associated with ADHD.

You are therefore asked to complete this response independently of the patient.

Some of the questions ask you to provide information about the person’s behaviour when they were a child, other questions ask about their current behaviours. If you are unable to answer any of the questions because you cannot remember or you have not viewed or been informed of their behaviour in a particular environment, please say so.

There are no wrong answers.

For example, parent, sibling, aunt, family friend
Declaration