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REFERRAL TO THE ADHD SERVICE (CHILDREN)

Following your contact with the practice, please complete this form in full. This is required for all ADHD service referrals.

Once the completed form has been returned it will be processed by our referral team.

Please note: This form is only for patients registered at this practice. If you have not previously discussed this referral with your GP we may reject your referral request.

Patient Details

Main Problems

Skills

Behaviour

Other Children

Emotions

Sleep

Exercise

Eating Habits

Sensory Issues

Childhood Experiences

Resources

Resources for parents including a webinar that discussed difficulties with attention, hyperactivity and impulsivity can be found by following this link: Advice and signposting – Children and Young People’s Services (sirona-cic.org.uk) It is important that you utilise these in order to help support your child/young person.

Please confirm if you have watched the webinar::

Please confirm if you have attended any courses to support your child/young person’s behaviour.

Bristol:

https://www.bristol.gov.uk/residents/social-care-and-health/children-and-families/support-for-parents-and-carers/parenting-courses-currently-running-in-bristol:

Yes/No:

South Glos

GlosSupport with parenting | South Gloucestershire (southglos.gov.uk)

Yes/No:

North Somerset:

About parenting and family support | North Somerset Online Directory (n-somerset.gov.uk)

Yes/No:

ADHD Scale

Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities:

Often has difficulty sustaining attention in tasks or play activities:

Often does not seem to listen when spoken to directly:

Often does not follow through on instructions and fails to finish schoolwork, chores or duties:

Often has difficulty organising tasks and activities:

Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework):

Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books or tools):

Often is distracted by extraneous stimuli:

Often is forgetful in daily activities:

Often fidgets with hands or feet or squirms in seat:

Often leaves seat in classroom or in other situations in which remaining seated is expected:

Often runs about or climbs excessively in situations in which it is inappropriate:

Often has difficulty playing or engaging in leisure activities quietly:

Often is “on the go” or often acts as if “driven by a motor”:

Often talks excessively:

Often blurts out answers before questions have been completed:

Often has difficulty awaiting turn:

Often interrupts or intrudes on others (e.g., butts into conversations/games):

Often loses temper:

Often argues with adults:

Often actively defies or refuses adult requests or rules:

Often deliberately does things that annoy other people:

Often blames others for his or her mistakes or misbehaviour:

Often is touchy or easily annoyed by others:

Often is angry and resentful:

Often is spiteful or vindictive:

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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REFERRAL TO THE ADHD SERVICE (CHILDREN)

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