Self Referral Form for ADHD Assessment

Self Funded (Private)

Please complete the following Self- Referral Form if you are seeking a private self-funded ADHD Assessment. This service is available for ages 7 to 65 years.

 For information on the process and fees please see our ADHD Assessment page, and Fees Page.

ADHD Assessment Self Referral Form Self Funding v1.26

ADHD Assessment Self Referral Form Self Funding v1.26

1. Who is Completing This Form?

This Self-Referral Form is suitable for ages 7–65 years old seeking a privately self-funded ADHD Assessment. A GP referral is not required.

Patients 18 years and over: Please complete this form yourself.

Patients 7 to 17 years: This form should be completed by a parent/carer with Parental Responsibility. If the patient is between 13 and 17 years, we request that they are aware of the referral and consent to the information provided.

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 adults screen, and HERE for link to children's 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.
The young person us consenting to this self referral.
Please confirm the young person is aware that information from the assessment will be available to you, their parent/ carer
This email will be sent questionnaires as part of the ADHD assessment
By providing the below contact details you are consenting for us to contact the facility 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 as the questionnaire link cannot be forwarded

5b. Adults Age 18 to 65 Years

Please choose the location of your ADHD assessment:
Remote assessments are shown to be just as valid and accurate as face to face, as the same in-depth, thorough assessment is undertaken.
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.
To support a smooth treatment pathway, we copy your ADHD report 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 imminently concerned about a patient’s safety, we are obligated to inform a patient’s GP and if appropriate, next of kin. They will only be contacted should there be an imminent threat of harm and we are unable to confirm patient safety.

8. Safety

The ADHD Assessment has three stages:

Stage 1: Self Referral Form and Payment.

Stage 2: Pre assessment screening questionnaires. Once your questionnaires are complete, we will be in touch to book your Clinical interview.

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.

9. Our ADHD Assessment Process

Agreement to Terms & Conditions

10. Real Time Test of Attention & Inhibition

QB Check is a software program that uses a real time test of attention and inhibition via a 30 minute task.
Why we recommend including a QB Check:
1. It removes subjectivity by precisely measuring movement and focus, offering a more reliable assessment of symptoms.
2. A QB can identify masked symptoms. It can detect issues with concentration and impulse control that may not be obvious during a standard clinical observation.
3. Studies show a QB can significantly increase diagnostic confidence, particularly when other conditions are present. It is recommended by NICE guidelines for children/ young people. A QB check incurs an additional fee of £145. Please see the QB YouTube video for more information.

11. Next Steps

Within the next 2 working days, we will send a payment link and contact you by email/ phone to answer any questions you may have.  Once payment is received, your pre-assessment questionnaires will be emailed out to you to start your assessment.
We will contact you shortly for payment and to send your pre-assessment questionnaires.