ADHD Referral Request

Are there any members of your family that have been diagnosed with ADHD? *

ADHD self-report scale

Please answer the questions below, rating yourself on each of the criteria shown using one of the answers provided. As you answer, select the answer that best describes how you have felt and conducted yourself over the past 6 months.

How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
How often do you have difficulty getting things in order when you have to do a task that requires organisation?
How often do you have problems remembering appointments or obligations?
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
How often do you feel overly active and compelled to do things, like you were driven by a motor?
How often do you make careless mistakes when you have to work on a boring or difficult project?
How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
How often do you misplace or have difficulty finding things at home or work?
How often are you distracted by activity or noise around you?
How often do you leave your seat in meetings or other situation in which you are expected to remain seated?
How often do you feel restless or fidgety?
How often do you have difficulty unwinding and relaxing when you have time to yourself?
How often do you find yourself talking too much when you are in social situations?
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?
How often do you have difficulty waiting your turn in situations when turn taking is required?
How often do you interrupt others when they are busy?

Further questions

The symptoms of attention deficit hyperactivity disorder (ADHD) can be categorised into 2 types of behavioural problems:

  • Inattentiveness (difficulty concentrating and focusing) – e.g. short attention span, constantly changing activities or tasks, difficulty organising tasks, appearing forgetful and losing things, making careless mistakes, being unable to stick to tasks that are tedious or time-consuming.
  • Hyperactivity and impulsiveness – e.g. acting without thinking, being unable to sit still, excessive talking, little or no sense of danger, being unable to concentrate on tasks.

Please give a detailed account of when you have presented with these symptoms or similar and how this has impacted your daily life.

Do you have any sleep problems? *
Have you suffered from mental health problems such as depression and anxiety or any other mental health problems? *
Have you been diagnosed with any learning difficulties (e.g. dyslexia)? *
Have you been diagnosed with any neurodevelopmental disorders (Tourette’s syndrome, epilepsy, autistic spectrum disorder (ASD), dyspraxia, head injury)? *
Do you have any physical health problems? *
Do you have any past or present history of misusing alcohol or illicit substances? *
Do you have any past or present forensic history, including driving offences? *
Please upload any relevant documentation:
Maximum upload size: 67.11MB