ADHD/MH Assessment Referral Form
Thanks for referring your client/patient to our nurse practitioner clinic for an assessment. We look forward to collaborating with you.
Please complete the following information to help with our assessment. Any information you can offer is greatly appreciated. When we receive your form we will contact the patient directly to schedule their assessment.
Name of Referring Provider
Full Name
Profession/Relationship
Referring Provider Phone Number:
Please enter a valid phone number.
Referring Provider Fax Number:
Only necessary if you would like a copy of the report, subject to patient's consent.
Name of Patient
First Name
Last Name
Patient has consented to being contacted by (please select all that apply):
Phone
Email
Patient Email Address:
example@example.com
Patient Phone Number:
Please enter a valid phone number.
For Physician referrals please indicate if referral is for:
Assessment and Consultation
Assessment and Treatment Initiation
Assessment and Ongoing Collaborative Care
What medications is the client/patient currently taking?
Please provide dose and indication.
Please provide a brief summary of the relevant symptoms you have observed in the referred patient:
Please provide a brief summary of the relevant symptoms the referred patient has reported:
Was the patient diagnosed with ADHD as a child?
Yes
No
Uncertain
Please upload any relevant lab work:
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Has the patient obtained a psychological or neuropsychological evaluation in the last 5 years?
Yes
No
If so, please upload a copy of the report:
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OR briefly summarize their findings:
Does the patient have any of the following:
Diagnosis of a bipolar disorder (including cyclothymia)
Diagnosis of a psychotic disorder
Diagnosis of a developmental or intellectual disability
Substance use disorder or history of a substance use disorder
History of psychological trauma
History of violence
Mental health related hospitalization (in last 5 years)
Lack of social support
Acute/Active suicidal ideation
If you've completed any of the following tools, please indicate the client's score:
Please include the date completed (ie. 9 - Jan. 01, 2023)
PHQ-9
GAD-7
ASRS Part A
ASRS Part B
Submit
Should be Empty: