Parent/Carer REFERRAL Information Request Pack 

Referrals will only be processed when accompanied by the referral packs.  

If a referring practitioner is unable to coordinate the completion of the packs, we will send a request for the packs to be completed.

Please be aware we only accept electronic referrals. 

On receipt of the fully completed referral pack, the multidisciplinary panel will screen these to assess whether further ADHD assessment is appropriate. If this is agreed, this will be added to the waiting list for ADHD assessment.

If we review all the information and decide that the evidence suggests that the young person does not need further ADHD assessment, then they will not be added to the waiting list for this and their referral to the ADHD assessment service will be closed. However, we will make recommendations of further support or assessment that may be helpful.

If you need any support completing this pack, please speak to the referrer.

Please make sure you have

  • Given as many examples as possible
  • Have provided any additional information you want us to know about 

PLEASE NOTE: WE WILL CONTACT SCHOOL/COLLEGE FOR INFORMATION SEPARATELY

Young person's details

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Date of birth Required
Invalid date
Is your child...
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Has your child previously been assessed in relation to ADHD? Required

Sharing and gathering information about you

As part of your assessment and treatment we gather information from other services, agencies and in combination with what you tell us about yourself, as this helps us to get a clear picture of your history and current needs, as well as any risk of harm to yourself or others.

The information gathering process will only relate to records that are relevant to your assessment and with the information you give us will be kept in your Health Record (written and computerised) to help us to provide you with the most appropriate care.

We have a duty to keep information about you private and confidential. However, in certain circumstances, there may be occasions where it is necessary to share information without your consent to protect you, or someone else, from harm. In these circumstances we will tell you that we are going to share information, what that information is and who we will share it with.

Do you consent to us seeking and sharing information as part of your assessment and treatment? Required
Are there any people you do not want us to contact? Required
Address
Address
Address

Statement of patient/parent/carer (only to be completed by parent/carer where the decision falls within the scope of parental responsibility or with the consent of a competent child/young person)

I give consent for ADHD services to access my/ my child’s/ young person’s records
Check box to add e-signature
Date
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To help us understand your child/ young person’s needs, we need some additional information about family circumstances, developmental history, and the young persons difficulties. This information is personal and sensitive and will help us to process the referral and support the assessment process.

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Adults living at home 

Date of birth
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Parental responsibility
Date of birth
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Parental responsibility
Date of birth
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Parental responsibility
Date of birth
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Parental responsibility
Date of birth
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Parental responsibility

Siblings

Date of birth
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Living at home?
Date of birth
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Living at home?
Date of birth
Invalid date
Living at home?
Date of birth
Invalid date
Living at home?
Date of birth
Invalid date
Living at home?

Medical history

Pregnancy details

Any previous miscarriages or stillbirths? Required
Did biological mother have any fever or infection during pregnancy? Required
Did biological mother have medical or mental health difficulties during the pregnancy? Required
Did biological mother require medication during the pregnancy e.g sodium valproate, gentamicin)? Required
Did biological mother smoke or drink alcohol during the pregnancy? Required
Did biological mother use street drugs during the pregnancy? Required
Were there any concerns about the baby’s growth or health from antenatal scans? Required
Did biological mother experience any traumatic events during the pregnancy? Required

Birth details

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Was baby born at full term of pregnancy? Required
Was the delivery: Required
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Did the baby require special neonatal care / support? Required
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Child development

Please state at what approximate age your child did the following:

Crawling

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Walking alone without support:

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Speaking:

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Smiling freely and appropriately towards you and others:

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Showing you things by pointing at them and looking back at you:

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Playing games like peek-a-boo:    

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Playing with objects by pretending to talk/imaginative play (e.g., talking on the phone/feeding a doll/flying a toy aeroplane etc.):

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Staying dry during the day:

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Staying dry during the night:

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Did the health visitor have any concerns about your child’s development in early years? Required
Did your child have speech and language assessments or therapy? Required

Child's Health

Has your child...

Ever been admitted to hospital? Required
Ever had any seizures, fits, faints, or other loss of consciousness? Required
Any other medical conditions or problems? Required
Ever had a head injury? Required
Had a hearing test? Required
Had a vision test? Required
Any medication/food allergies? Required
Are immunisations/ vaccinations all up to date? Required
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Concerns

Please give details on the following concerns:

SNAP-IV

In answering the following questions, please consider whether the behaviour has persisted for at least 6 months

For each item, select the box that best describes this child. Put only one check per item.

Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities Required
Often has difficulty sustaining attention in tasks or play activities Required
Often does not seem to listen when spoken to directly Required
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties Required
Often has difficulty organising tasks and activities Required
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework) Required
Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) Required
Often is distracted by extraneous stimuli Required
Often is forgetful in daily activities Required
Often fidgets with hands or feet or squirms in seat Required
Often leaves seat in classroom or in other situations in which remaining seated Required
Often runs about or climbs excessively in situations in which it is inappropriate Required
Often has difficulty playing or engaging in leisure activities quietly Required
Often is “on the go” or often acts if “driven by a motor” Required
Often talks excessively Required
Often blurts out answers before questions have been completed Required
Often has difficulty awaiting turn Required
Often interrupts or intrudes on others (e.g., butts into conversations/games) Required
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Communication

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Relationships with peers

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Routines

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