Therapist ADHD referral

Therapist Observation Form for ADHD evaluation or Therapist Referral for ADHD Evaluation
Instructions for mental health professional:

A client under your care has either been referred to us by you, or is requesting an ADHD diagnostic evaluation with our clinic. We kindly ask for your feedback and observations to help us with this evaluation.

Please complete all of the following sections as thoroughly as possible. If a section does not apply, please write N/A. In addition to this Form, we recommend sending a current release of information, and any treatment records you have that are relevant to this evaluation. We may contact you to further discuss this client. You may also reach out to the clinic to schedule a phone consultation.

Additionally, this form is available via electronic submission our website.
Client Name
Date of Birth

MonthDayYear
Date
I. Summary of Current Treatment Length of treatment:
Beginning date

MonthDayYear
Date
End date (If applicable)

MonthDayYear
Date
Frequency of appointments
Focus of (current or previous) work with client:
Reason For Referral:

Client RequestTherapist Recommended/ ReferredEstablished RMH client
Assessment of Current Functioning
Any concerns for safety if yes do they have a safety plan in place
Specific observations or concerns for ADHD
Have you conducted and ADHD evaluations or screeners if yes please describe or send records
Your clinical impressions insights and assessment in relation to a possible ADHD DX
Any other mental health concerns or additional Information Relevant to Clients care
Thank you for this referral. Please fax or email this form to us, or fill it out on our website. It is also helpful to send a current release of information, and any additional relevant treatment records to our clinic. Please feel free to reach out to the clinic if you would like to schedule a phone consolation to discuss this client.
Signature of Referring Provider

Clear
Name of Referring Provider
Practice Information
Best method of communication
File Upload: Records and Signed Release of Information:

Recommended
Cancelof
Practice Email: admin@rainbowmentalhealth.co P: (224) 263-4671 F: (224) 364-6471 http://www.rainbowmentalhealth.co/
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Therapist Observation Form for ADHD evaluation or Therapist Referral for ADHD Evaluation

Practice Email: admin@rainbowmentalhealth.co P: (224) 263-4671 F: (224) 364-6471 http://www.rainbowmentalhealth.co/