Registration Form
Right to Choose ADHD Assessment

Ages 7 years to 65 years

Please read our eligibility criteria to confirm you meet the Right to Choose Criteria.

You will need a GP referral to activate Right to Choose.

At present, only patients with GPs in Hereford and Worcestershire or with GPs within the Black Country are eligible for our Right to Choose ADHD Assessments. Please speak to your GP to confirm they come under the above Integrated Care Trust (ICB). This may also be on their website.

Please complete the below form either prior to making a GP appointment, or alternatively once the GP has sent us your referral. To progress your referral to the next stage we need both forms to be complete: (1) a GP referral and (2) completion of this Registration Form. Please use the same names and contact details so we can match the forms.

Register for Right to Choose ADHD Assessment

Register for Right to Choose ADHD Assessment

1. Eligibility for Right to Choose

Our service offers Right to Choose to patients registered with a GP in Hereford and Worcestershire.
If you are unsure if your GP Practice comes under Hereford and Worcestershire ICB please visit the practice website or telephone your GP practice to enquire.
Who is completing this form?
Please confirm you have parental responsibility

Eligibility Criteria

Previous ADHD Assessments 

  • You have not previously been assessed for ADHD by the NHS and are seeking a second opinion. 

Age, Communication, and Development 

  • You are between 7- 17 years for a Child Assessment or 18- 65 years for an Adult Assessment.
  • You are able to communicate fluently in English and are not non-verbal or selectively mute.
  • You do not have a significant intellectual disability (IQ below 70) or severe developmental delay. 
  • You do not have a neurological condition, traumatic brain injury, or history of brain surgery that affects cognitive function. 

Sensory, Mental Health, and Risk Factors 

  • You are not currently experiencing psychosis or have had a psychotic episode within the past six months. 
  • You do not pose a risk to yourself or others, have made a suicide plan or attempt in the last six months, or are actively self-harming. 
  • You are not currently receiving treatment for an eating disorder or are awaiting treatment. 
  • If recently discharged from a specialist eating disorder service, at least six months has passed before referring for an assessment. 
  • You must not have a significant alcohol or drug use concern.
  • You must not currently be in treatment for substance addiction.

Legal and Safeguarding Concerns  

  • You must not be currently detained in a hospital under the Mental Health Act 1983 or are under a Community Treatment Order. 
  • You must not be serving a prison sentence, on probation, or temporarily released from custody. 
  • You must not be involved in an active police or criminal investigation, undergoing a safeguarding investigation or subject to a child protection plan. 
  • An assessment can only proceed once these matters are fully resolved.

Military Status 

  • You are not a serving member of the Armed Forces. 
Please read the above eligibility criteria.

2. Privacy of Information

We take the privacy and security of your personal data very seriously. This Self Referral Form requests personal information, collected and processed in line with strict GDPR guidance. For further information please see our Privacy Policy.
Please confirm you aware of the companies privacy policy that the information provided is to be used for the purposes of an ADHD assessment.

3. Screening for ADHD Symptoms

We recommend all patients undertake a screening questionnaire prior to booking an ADHD Assessment to confirm symptoms are present. Click HERE for link to an adults screen, and HERE for a link to a children's/ young person's ADHD screen.

Please tick to confirm

4. Patient Details

Please do not leave spaces
If the patient is an adult we request their own email address is provided. If the patient is under 18 years please provide a parent/ carer email address.
Does the above email and mobile phone number belong to the patient?
Please note that anyone with access to the above email/ mobile will have access to personal clinical information and appointment details.

5a. Children & Young People Age 7 to 17.5 Years

All child/ young person ADHD assessments are conducted face to face.
Do they consent to a referral for an ADHD assessment?
This email will be sent questionnaires as part of the ADHD assessment
Is the young person aware that information from the assessment will be available to their parent/ carer who has access to the above email/mobile

We focus on providing accurate and thorough assessments. Accuracy is increased by collecting evidence from individuals who know the patient well, ideally from birth. This person is called a Childhood Observer.

By providing contact details below, you are consenting to being sent questionnaires as the patients Childhood Observer. 

By providing the below contact details you are consenting for us to contact the facility/ educational person to request further information.
Please also obtain the consent of your young person to contact the school (if aged between 13 and 17.5 years).
We require their direct email so we can send them the link to their questionnaire

5b. Adults Age 18 to 65 Years

Please choose the location of your ADHD assessment:
Remote assessments are accurate and valid as the same in-depth, thorough assessment is undertaken, using all pre-assessment questionnaires and a clinical interview.
We focus on providing accurate and thorough assessments. Accuracy is increased by collecting evidence from individuals who know you well. By providing their contact details, you are agreeing for us to send a questionnaire to your Observers.

Please confirm if you can provide the following information:

Childhood Observer
Current Observer (Ideally someone who knows you well day to day).
School Reports are extremely helpful. Please try to locate old school reports if possible. We will ask more about these in the pre-assessment questionnaires.

6. GP Details

Your GP will be contacted with the outcome of the assessment.
We are required to provide a copy of your ADHD assessment to your GP, so they can support you with ADHD treatment in the future (medication/ therapy).

7. Consent to share information

Should you wish another person (i.e. family member) to have access to personal clinical information and appointment details, please name them below. This means you are giving permission for us to release information to them about your assessment and appointment details, should they contact us directly.

Should we be seriously and/ or imminently concerned about a patient’s safety, we are obligated to inform a patient’s GP and/ or the local safeguarding team and if appropriate, next of kin. In extreme circumstances of imminent risk we may call 999.

Should you cancel your appointment with less than 48 hours’ notice, the appointment will be charged to the NHS, and you may forfeit your opportunity to access our services. If two appointments are cancelled with less than 48 hours’ notice, we will be required to discharge you, in accordance with the requirements of our Right to Choose contract.

Further information can be found in our Terms and Conditions of using Midlands ADHD Clinic.

Agreement to limits of confidentiality & cancellation conditions

8. Safety

9. Our ADHD Assessment Process

The ADHD Assessment has three stages:

Stage 1: Registration Form and GP referral
Stage 2: Pre assessment screening questionnaires.
Stage 3: Clinical Interview. This will take place as a 3 hour appointment (including a 30 minute break).

The following Terms and Conditions outline the expectations when engaging with our service.

Please read in full as they refer to important aspects such as late cancellations, confidentiality and refunds. Our Terms and Conditions will also be available in a link in your booking email.

Agreement to Terms & Conditions

10. GP Letter

If you have already spoken to your GP and they have activated a referral please go to Section 11.

If you have not yet spoken to your GP, we have created a letter to give to them, to support your referral. It is available to download HERE

You are welcome to print and take this letter to your GP, or download and show your GP on your phone/ tablet.

______________________________

Dear GP

RE: Right to Choose (RTC) referral for an ADHD assessment
I would like to formally request a Right to Choose referral to Midlands ADHD clinic for an ADHD Assessment.

Patient Name:
Patient DOB:

Eligibility
In line with NHS protocols a screening measure has been completed which indicates symptoms in line with possible ADHD. The patient also meets the Right to Choose eligibility criteria.

Polite Request
To proceed with the referral, I kindly ask if you will complete a referral to Midlands ADHD Clinic via the NHS electronic referral system e-RS. 

About Midlands ADHD Clinic
Midlands ADHD Clinic is an approved provider under the NHS Right to Choose (RtC) pathway and holds a commissioned contract with the Herefordshire and Worcestershire Integrated Care Board (ICB) to deliver the following services:

1. Child ADHD Assessments (ages 7 to 17) undertaken face-to-face.
2. Adult ADHD Assessments (age 18+) undertaken either face-to-face or remotely.
3. Initiation and titration of ADHD medication (age 18+).

Midlands ADHD Clinic, established in 2013, delivers high-quality, evidence-based mental health care with a specialist focus on the assessment, diagnosis, and treatment of ADHD.

The clinic is supported by a large, multidisciplinary team and adopts a thorough, person-centred approach, dedicating at minimum of three hours of assessment time to each patient, with comprehensive information collected and analysed prior to the clinical interview. Where co-occurring conditions are identified, an individualised treatment plan is developed. This may include, for example, interventions such as CBT for anxiety or depression, or Eye Movement Desensitisation and Reprocessing (EMDR) for trauma, or attachment-based therapy for relationship breakdown.

If you have any questions regarding the information in this letter, please contact support@midlandsadhdclinic.co.uk

Yours sincerely,
[Patient name]

RTC Contract Details
Contract Title: ADHD CYP and Adults – Midlands ADHD Clinic Ltd trading as Malvern Hills Private Practice / Midlands ADHD Clinic.
Contract Type: NHS Standard Contract 2024/25. Reference: ADHD-CYP_Ad – Midlands ADHD Clinic 2526. Signing Parties: Hereford and Worcester Integrated Care Board and Midlands ADHD Clinic Ltd

11. Next Step

If you have yet to visit your GP, please book an appointment and show your GP the above letter. They can make a referral through the Electronic Referral System (e-RS).