Adult ADHD Referral - Grays Inn Medical Group

What will happen next?

After completing this form, your GP practice will refer you to Psychiatry UK using the details you fill out below alongside information from your medical record.

Do I still need to book an appointment?

You do not need to book an appointment with a GP as you will be directly referred to the ADHD assessment service after completing this form. You are welcome to arrange an appointment if you feel to need to speak to a GP for advice or to discuss any additional concerns.

How long are the waiting times?

We do not have access to waiting time data and please be aware that even the service provider may not be able to estimate the waiting time as this can vary depending on service conditions and the type of assessment that you require. Your waiting time may range from many months to multiple years depending on the conditions of the service.

Patient Name *

First

Last

Date of Birth *

Mobile Number *

Which practice are you registered with?

Reason for referral *

Give us a comprehensive description of symptoms, background, impact on daily life and additional information

Please answer the questions below, stating which best describes how you have felt and conducted yourself over the past 6 months.

1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? *

2. How often do you have difficulty getting things in order when you have to do a task that requires organization? *

3. How often do you have problems remembering appointments or obligations? *

4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? *

5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? *

6. How often do you feel overly active and compelled to do things, like you were driven by a motor? *

7. How often do you make careless mistakes when you have to work on a boring or difficult project? *

8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? *

9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? *

10. How often do you misplace or have difficulty finding things at home or at work? *

11. How often are you distracted by activity or noise around you? *

12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? *

13. How often do you feel restless or fidgety? *

14. How often do you have difficulty unwinding and relaxing when you have time to yourself? *

15. How often do you find yourself talking too much when you are in social situations? *

16. 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? *

17. How often do you have difficulty waiting your turn in situations when turn taking is required? *

18. How often do you interrupt others when they are busy? *