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REFERRAL TO THE ADHD SERVICE

Following your contact with the practice, please complete this form in full. This is required for all ADHD service referrals.

Once the completed form has been returned it will be processed by our referral team.

Please note: This form is only for patients registered at this practice. If you have not previously discussed this referral with your GP we may reject your referral request.

Patient Details

Select a Service

Avon and Wiltshire Mental Health Partnership (AWP) are the NHS ADHD service for adults aged 18 years and over in this area.

You may be aware there are several other services offering ADHD assessment, please indicate below which service you would like to be referred to. When choosing the service you wish to be referred to please ensure you are aware what each organisation are able to offer you.

For more info please read this page, which also includes a spreadsheet that summarises the current services offered by providers, including referral information and exclusions.

Please be aware, you may be asked to choose an alternative service if your chosen provider does not engage with our local referral processes. We will contact you if this is necessary.

Select a service: *

*ProblemShared is not currently accepting the practice's preferred referral process, so has been excluded from the options above.

Main Problems

i.e. inattention, hyper-activity, impulsivity

Developmental History

Did you have any of the following?:

i.e. autism, specific learning difficulty, learning disability etc.

i.e. trauma, abuse, parental mental health problems, parental substance abuse etc.

Family History

Please give details of familial relationship and diagnosis

Any known family history of the following?:

Education/Work History

Currently in education?: *

Are school reports available for any of the problems raised above?:

Currently working?:

Sleep, Drug and Alcohol History

Any daytime naps in the week? Bedtime? How long does it take to fall asleep? Sleep more often broken or solid? Waking up time? Morning or evening type?

ASRS Questionnaire

Please answer the questions below, rating yourself on each of the criteria shown. Choose the option that best describes how you have felt and conducted yourself over the past 6 months.

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

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

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

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

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

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

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

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

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

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

11. How often are you distracted by activity or noise around you?: *

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

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

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

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 them themselves?: *

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

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

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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CONTACT DETAILS

The Family Practice
Western College
Cotham
Bristol
BS6 6DF

Reception: 0117 946 6455
Fax: 0117 974 3112
Out Of Hours:111

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