Cognition Care – ADHD Referral Form

Cognition Care – Referral Form

Please complete this secure form to refer a patient to Cognition Care. This form can be used for referrals related to ADHD, autism, or other mental health concerns in both children and adults.
About the Referrer
Referrer Full Name

First NameLast Name
Referrer Email
example@example.com
Referrer Phone
Please enter a valid phone number.
Your Role or Relationship to the Patient
Referrer Role / Job Title
e.g. GP, CAMHS practitioner, SENCO, private therapist)
Organisation / Practice Name
(e.g. school, clinic, trust, or surgery name)
Referrer’s Professional Registration (Optional)
Professional Registration Number (if applicable)
Individual Being Referred
Patient Details
Date of birth

MonthDayYear
Date
Gender
NHS Number (if known)
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email or Contact Number of Individual / Parent / Carer
GP Name and Practice (if known)
Concerns & Relevant History
Reason for Referral
What is the primary reason for referral? (Tick all that apply)

ADHD (Adult)ADHD (Child)Autism (Adult)Autism (Child)General mental health concernsOther
Reason for Referral (concerns, symptoms, relevant history)
Previous Assessments / Diagnoses (if any)
Safeguarding Concerns or Relevant Risks
Upload Supporting Documents

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Consent & Privacy
I confirm that the individual (or their parent/carer) has given consent for this referral.

Yes
Privacy Notice

Cognition Care will process this referral form in line with UK GDPR for the purpose of assessment and care planning. For more details, visit: www.cognitioncare.uk/privacy
Referrer Signature

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Date of Submission

MonthDayYear
Date
Gender
Should be Empty:

Cognition Care – Referral Form

Reason for Referral