ADHD/ASC Registration Form for Adults

ADHD/ASC Registration Form for Adults

If you are 18 or older, please complete this registration form.
(If you are younger than 18, please see our registration form for young people.)

We are pleased you have decided to take this step in seeking a Neurodevelopmental assessment. It is a courageous step.

The questions below are designed to provide us with important information about you. Some questions may bring up some emotions, and some may not feel relevant to you. That is okay.

We ask for brief descriptions in these questions, and will go through relevant answers in more detail in the assessment process.

If there are any questions you are unsure of, please contact us on info@dianneeveritt.com, and we will be happy to guide you.
Full Name*

First NameLast NameInitials
Residential Address*

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Date of Birth*

MonthDayYear
Date
Occupation*
Phone Number*

Country CodePhone Number
E-mail*
example@example.com
Gender*
If other, please specify
What pronouns would you like us to use in the report?
How did you find us?*
If other, please specify
Next of Kin (Person to Contact in Case of Emergency)*

Street Address

Full name

Relationship to youContact Number

Postal / Zip Code
GP Details*

Name of GP

Name of GP Surgery

Contact NumberState / Province

Postal / Zip Code
Method of Funding*
Health Insurance Pre-authorization Number, if applicable
Reason for Referral
What has lead you to seeking an assessment?
Please describe your main concerns?
Early Childhood
How would you describe your childhood? (Happy, loving, supported, difficult, traumatic, isolated, etc?)
Did you have any special interests as a child?
Were you good at remembering and noticing details that others typically don't? For example, specific dates, birthdays, types of aeroplanes etc?
Social Development
How would you describe your social interactions as a child? (Choose all the apply)

I preferred to play aloneI had difficulty making friendsI had many friendsI was very social and outgoingOther (please specify below)
If other, please specify
How did you respond to new people as a child?
How would you respond to unexpected changes or sudden changes to plans or routine as a child?
How adaptable would you say you are to unexpected changes now?
Educational and Work History
Did you have any difficulties at school? If yes, please briefly specify
Did you repeat an academic year, or modules, either at School or University?

YesNo
If yes, please specify
How did you do academically in school?
Do you think you met your academic potential at school?

YesNoSometimes
How did you prepare for exams at School?
Have you ever dropped out of, or failed to complete any degree/diploma or other form of formal education?

YesNo
What is your highest level of education?
Have you made any significant career changes since the start of your career? If so, please specify
Family History
Does anyone in your immediate or extended family have a diagnosis of Attention Deficit and Hyperactivity Disorder (ADHD), Autistic Spectrum Disorder (ASD), or learning difficulty like dyslexia, dyspraxia or dyscalculia?

YesNo
If yes, please specify the family member's relation to you, and their diagnosis. There may be more than one.
Do you suspect any members of your immediate family may have a neurodevelopmental condition undiagnosed?

YesNoNot sure
Do any members of your immediate family have any other mental health diagnoses? Please specify who they are in relation to you and their diagnosis.
Mental Health History
Have you ever been diagnosed with, or suspect you may have any of the following?

AnxietyDepressionBipolar DisorderPersonality DisorderOCDPsychosisPTSDAutistic Spectrum ConditionADHDPanic DisorderOther
Do you, or have you had any significant difficulties with sleep? If so, please give a brief description?
How do you cope with stress in your life now? What are some of your strategies when you experience stress?
Have you ever received support for your mental health, such as from a Psychologist, Psychiatrist, employee assistant program, or remedial teacher? If so, please specify
Are you currently getting support for your mental health? If so, please specify
Are you currently taking medication for your mental health? If so, please list them below.
Have you ever struggled with substance/alcohol abuse or dependence?

YesNoNot sure
Risk
Have you ever made a suicide attempt?

YesNo
Have you ever self-harmed?

YesNo
Are you currently experiencing suicidal thoughts?

YesNoNot sure
Have you ever had thoughts of harming anyone else?

YesNoNot sure
If yes to the above, please provide a brief overview of the context?
*If you feel that your life may be at risk, please take yourself to your closest A&E department, or call 111 for assistance.
As a child, did you engage in risk-taking behaviours? Shoplifting, playing with fires, breaking the law, gambling etc?
Have you ever been in trouble with the law?

YesNoNot sure
Physical Health
Do you have any health conditions? If so, please specify and state when you were diagnosed
Have you ever had a head injury?

YesNoUnsure
If yes, please tell us what happened, when it happened, and whether you had a concussion?
Do you have any other medical history that has not been covered here? If so, please specify
Do you have any disabilities? If so, please specify
Are you pregnant or breastfeeding?

YesNoNot sureNot applicable
Please describe how you think your difficulties are impacting your life, and what areas are most affected (e.g. work, relationships, managing yourself, mental health, self-esteem etc)
Please read our terms and conditions. Our full terms and conditions can be found here. By checking the boxes below, you acknowledge that you have read the terms and conditions, and agree to them whilst working with any of the Clinical or Counseling Psychologists at Dianne Everitt and Associates.

Please take particular note of the following in realtion to fees and cancellation of sessions.

Cancellation Policy

As ADHD appointments last between 2-3 hours, this is a significant amount of time that our Psychologists allocate to the assessment. These appointments are carefully planned and allocated, and we appreciate as much notice as possible should any changes be needed.

If you cancel the assessment within 48 hours, you will be charged £300.

If you reschedule with less than 48 hours notice, you will be charged £100.

If you fail to cancel the appointment, you will be charged £300.

Settlement of Fees

You will be liable for the settlement of fees, which can be paid by bank transfer following the receipt of an invoice.

If you are using insurance to cover the cost of your sessions, please note that you need to obtain preauthorization before the first appointment, and there may be an excess for you to cover, depending on your policy. We will need confirmation from your insurer, stating they will cover the entire cost of the session, which is £1195. If they do not cover this, you will be liable for the full fee.
Acceptance of terms and conditions*

I acknowledge that I have read the full terms and conditions, and agree to themI accept the cancellation policyI accept responsibility for the settlement of fees, and will be liable if my insurance does not cover this
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ADHD/ASC Registration Form for Adults

Reason for Referral

Early Childhood

Social Development

Educational and Work History

Family History

Mental Health History

Risk

Physical Health