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

1. How to complete 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.

Please select the age of the person seeking an ADHD assessment:

If you are completing this form as a parent/ carer please provide your full name below and your relationship to the child/ young person.

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 company's privacy policy that the information provided is to be used for the purposes of an ADHD assessment.

I agree for Midlands ADHD Clinic to collect and process my information in line with strict GDPR guidance.

3. Patient Details

First Name

Surname

Age

Date of Birth

First line of address

Second line of address

Town/ City

Post Code

Preferred Pronouns

Mobile

Please do not leave spaces

Email address

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?

Yes they are mine (the patient's) own email and mobile

No the email and mobile belong to a parent/ carer/ support person

Please note that anyone with access to the above email/ mobile will have access to personal clinical information and appointment details.

I am an adult and I consent to the above contact details being used on my behalf

The contact details belong to the parent/ carer of the patient who is between 7 and 17 years).

If there are any adjustments needed to access the appointment, please write below or leave blank.

4a. Children & Young People Age 7 to 17.5 Years

All child/ young person ADHD assessments are conducted face to face.

How old is the patient at the time of completing this form?

Please confirm that the young person is consenting to this self referral and they are aware we may contact their school.

I confirm they are aware and consent to this referral

Please confirm that all parties with parental responsibility (PR) consent to this referral.

I confirm that all parties are aware and consent to this referral

Please confirm the young person is aware that information from the assessment will be available to you, their parent/ carer

I confirm they are aware and have agreed I can have access to their health and appointment information.

Parent/ Carer First Name

Parent/ Carer Surname

Relationship to Patient

Mobile

This email will be sent parent/ carer questionnaires as part of the ADHD assessment

4b. Adults Age 18 to 65 Years

Please choose the location of your ADHD assessment:

Face to face ADHD assessment in our Malvern clinic

Remote ADHD assessment via video

Remote or face to face. The next available please.

Remote assessments are shown to be just as valid and accurate as face to face, as the same in-depth, thorough assessment is undertaken.

5. Our ADHD Assessment Process

The ADHD Assessment has three stages:

Stage 1: Self Referral Form and Payment.

Stage 2: We will email your 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.

Agreement to Terms & Conditions

I confirm I have read and agree to the above terms and conditions.

6. 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.

7. Next Steps

Please include a QB Check: Real time test of attention/ inhibition/ impulsivity

Within the next 2 working days, we will send a payment link for your ADHD assessment. Once payment is received, your pre-assessment questionnaires will be emailed out to you to start your assessment.

Thank you for trusting Midlands ADHD clinic with your ADHD assessment. We will contact you shortly via email with a payment link

I will look out for the email to start the process