Child Self Referral Form

Child Self Referral Form
Child information
Title

Other
Childs Name

Childs First NameChilds Surname
Childs preferred Name
Childs Date of Birth

DayMonthYear
Date
Childs Age
Childs Sex
Childs Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent or Carer Information
Parent or Carer Name

Parent or Carer Forename(s)Parent or Carer Surname
Relationship to Child
Parent or Carer Phone Number
Parent or Carer Address if Different
Add N/A if not applicable
Parent or Carer Email
example@example.com
What is your preferred method of contact? Please note that the majority of our communications are delivered via email and automated system updates
We will be sending your child's assessment forms via Email, please let us know if you need an alternative option, i.e. Post?
Do you have parental responsibility?
A comprehensive ADHD/ASD assessment is most effective when it includes input from all those who play a key role in a child's life. If parents are separated, we encourage both to contribute to the assessment process, as this helps ensure a balanced and complete understanding of the child's needs.

If there is disagreement over assessment, it is not Makewell's role to mediate between parents or to resolve disputes and we may require legal confirmation of parental responsibility and consent before moving forward. If you have any concerns about parental involvement, please let us know as soon as possible.
Please confirm if both parents are attending the appointments if separated.
If not both attending, please confirm that the other parent is aware of the appointment.
Additional Parent Contact Information (Optional)
Additional Parent or Carer Name

Parent or Carer Forename(s)Parent or Carer Surname
Additional Parent or carer relationship to Child
Do you have parental responsibility?
Additional Parent or Carer's Address
Additional Parent or Carer's Phone Number
Additional Parent or Carer's Email
example@example.com
Contact preferences
GP Information and Other Contacts
Name of Childs GP Surgery
GP Surgery Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GP Surgery Phone Number
GP Email address if known
example@example.com
Do you consent to us contacting your GP surgery?
Is Your Child a Looked After Child?
Does the child have a social worker?
If yes, please provide name of social worker

SW First NameSW Last Name
Phone Number for social worker
Important ADHD Appointment Preparation

To make sure there are no delays in your child’s ADHD assessment, it’s really important that the school completes two short documents as soon as possible. We’d be grateful if you could help by reminding the school, as this paperwork is an essential part of the process.
Name of Childs School
School Address
Name of Teacher or key contact at Childs School
School's Email address
Do you consent to us contacting your school
Optional Additional Information about your child
Child's Ethnicity
Assessment Information
Which service do you require?
Is your child in contact with any other professionals? (Examples may be CAMHS, Social Care, Educational Psychology, Private Therapy involved)
Please list
Has your child had a previous assessment for ADHD or Autism, or have they have an existing diagnosis?
If yes please give details
Please give a brief description of who your child lives with at home:
Please give a brief summary of your child's overall health and give details of any physical health issues:
Does your child have a history of learning disabilities or difficulties at school? If yes please give details:
Does your child have a history of mental health diagnosis or difficulties? If yes please give details:
Please list any medication your child takes for mental health or physical health:
Who prescribes this medication GP, Hospital consultant or other?
Has your child experienced current or past trauma? Examples may include abuse domestic violence bereavement witnessing a traumatic event. If yes, please give details:
Does your child use alcohol tobacco or recreational drugs? If yes please give details:
Has your child had any current or historical involvement with the police or legal services? If yes, please give details:
Has your child experienced or are they currently at risk from deliberate self harm suicidal behaviour running away or exploitation? If yes, please give details:
Has your child ever been in any situations where they have been verbally and or physically aggressive? If yes, please give details:
Is there any other information we need to be aware of? Please share overall difficulties with day-to-day living, relationships, social situations etc that may be relevant.
Introducing Ava our friendly therapy dog, here to help create a calm and comforting environment. Do you have any allergies we should be aware of?
If Ava is on site and available, would you like her to attend your appointment? (Please note, Ava is not available for medication appointments).
We’re happy to look for the next available appointment, would you like us to offer that, or would you prefer to schedule it for a later month to help manage costs? We’ll do our best to accommodate your needs.
Medication Services

***If applicable***
Full diagnostic ADHD Report upload

Cancelof
Consent to Assessment by Parent or Legal Guardian

IMPORTANT
Makewell Clinicians will explain each part of your child's assessment to you and will encourage you to ask any questions you may have. Please don't hesitate to ask for additional information at any time.

I consent to my child having an assessment at Makewell Clinic and understand that all assessment stages will be fully explained to me.
Parent or Carers Name
Relationship to Child
Parent or Carer's Signature
Date

DayMonthYear
Privacy Notice

IMPORTANT
Medical records will be held securely via our GDPR compliant clinical system. Our privacy policy can be found on our website or by clicking here Privacy Notice. Please confirm that you have read this policy. By accepting an appointment, you confirm that you agree with our terms.

IMPORTANT

I confirm I have read the Privacy Notice and agree to the Terms and Conditions
Parent or Carer's Name
Parent or Carer's Signature
Date

DayMonthYear
Marketing Preferences
In addition to the clinical information that we share with you and key members of the health and care team, we may occasionally send you information about our services. We value your privacy and want to ensure that you are happy to receive this information from Makewell in a way that suits you. Please take a moment to indicate your marketing preferences below.
Where did you hear about us? If a school, clinic, organisation, or other source please include the name.

Other
Should be Empty:

Child Self Referral Form

Child information

Parent or Carer Information

Additional Parent Contact Information (Optional)

GP Information and Other Contacts

Important ADHD Appointment Preparation

Optional Additional Information about your child

Assessment Information

Medication Services

Consent to Assessment by Parent or Legal Guardian

Privacy Notice

Marketing Preferences