Self Referral Form for ADHD Medication

Ages 11 to 65 years

This Self Referral Form is for patients seeking ADHD Medication, privately funded. Please see our below eligibility criteria prior to completing this form. For information on the process please see our Medication page.

Self Referral Form for ADHD Medication

Ages 11 to 65 years

This Self Referral Form is for patients seeking ADHD Medication, privately funded. Please see our below Eligibility Criteria prior to completing this form. For information on the process please see our Medication page.

Midlands ADHD Clinic: Self Referral for ADHD Medication

Patient Details

Who is completing this form?

I am an adult. I am completing this form for myself

I am completing this form on behalf of a minor (11 to 17 yrs old) and I have parental responsibility.

Please state your full name and relationship to the child/ young person.

Full name of patient

First Name

Last Name

Patient's date of birth (dd.mm.yyyy)

Patient's age

Patient's address (first line)

Patients are welcome from England, Scotland and Wales. We are unable to see patients in NI due to prescription restrictions.

Patient's address (second line)

Town/ city

Postcode

Patient's email contact

If the patient is over 18 years, this will ideally be their own email. The patient MUST have access to this email during each consultation as it will be used to email their Consent Form.

Patient's mobile phone number

For patients over 18 years, this will ideally be their own mobile.

If the contact details provided do not belong to the patient, please confirm that the patient has given permission for these details to be used as their primary contact:

The contact details above belong to the patient.

The contact details above do not belong to the patient. The patient has given permission for these details to be used and understands that the owner of the email address or mobile number will have access to their medical information.

Please confirm the patient will have access to the above contact details during each medication appointment:

Yes the patient will have access to both mobile and email during the consultation.

Our Prescribers will send Consent Forms to the contact details, to be completed during the appointment.

Please confirm that should you make any online bookings (via our website) you will use only the above patient name, email and mobile to make the booking

I confirm I will use the above patient name, email and mobile when making a booking for this patient.

Should you make a booking in a different name or email, we will be unable to link up your clinical profile with the booking and your appointment may be postponed.

Name of G.P.

Your GP practice will be provided with information regarding your medication consultations.

G.P. practice name

First line of G.P. practice address

Postcode of G.P. practice

Evidence of your ADHD Assessment and Diagnosis

Who undertook the original ADHD assessment?

A Psychologist within Midlands ADHD Clinic or Malvern Hills Private Practice

A Psychologist registered on our ADHD Partnership Pathway (please provide assessors name) A Psychologist registered on our ADHD Partnership Pathway (please provide assessors name)

An NHS service

A Right to Choose provider

OtherOther

When did the ADHD assessment take place? (mm/yy)

[Essential] Please upload your FULL Clinical Assessment Report. A summary is not sufficient, as your Prescriber will need to read the full report. (If you were diagnosed by Midlands ADHD Clinic or Malvern Hills Private Practice please leave blank).

Maximum file size: 33.55MB

PDF, DOC, DOCX . We can only progress your self referral if we have a copy of your full ADHD report.

If your document has been password protected, please email your password to support@midlandsadhdclinic.co.uk. Please include the patients full name in the subject line.

I have emailed the password

My report is not password protected

Preparing for your Medication Consultation

Please note that you are requesting an 'assessment' for medication. We cannot guarantee that your Prescriber will, at this time, provide ADHD medication. It is at their discretion following a thorough assessment.

I understand, the first appointment in an assessment for possible medication

Our Prescribers are highly trained and experienced. They will only provide prescriptions in line with NICE guidelines based on patient safety and clinical appropriateness.

Please read through the following information so you are aware of the terms and conditions of using our service:

Terms & Conditions – Midlands ADHD Clinic

Information on fees and the process can be found here:

Medication – Midlands ADHD Clinic

Please confirm you accept the terms and conditions of booking as outlined above.

I accept the Terms and Conditions

We require all patients to regularly monitor blood pressure and pulse rate. We recommend purchasing a blood pressure cuff, they are sold at amazon or local pharmacies.

I agree to monitor weight, blood pressure and pulse rate.

Please purchase a BP machine asap. Your pulse rate and blood pressure will be needed for your Health Screening Form which is the next step in this process. Alternatively you can monitor your blood pressure via your local pharmacy. Please note you may need daily recordings.

We recommend speaking to your GP prior to your medication assessment. This is especially imortant if you wish to access Shared Care at the end of this process as Shared Care is at the discretion of your GP

I understand

Following completion of this form, we will send you an email with a link to complete your Health Screening Form.

I will look out for the email, complete and submit the Health Screen

Please check your spam folder in case it lands there.

If you are human, leave this field blank.