Adult Self Referral Form

Adult Self Referral Form
Title
Your Name

Forename(s)Surname
Your Preferred Name
Your Date of Birth

DayMonthYear
Date
Your Sex
Your Age
Your Telephone number
Your Email address
example@example.com
Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GP Information
GP Surgery Name
GP Surgery Address
GP Phone Number
GP Email address
Do you consent to us contacting your GP surgery?
Optional Additional Information
Your Ethnicity
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 assessment forms via Email, please let us know if you need an alternative option, i.e. Post?
Additional Information
Which service do you require?
Are you in regular contact with any healthcare professionals? (Examples may be Mental Health Services, Social Care, Private Therapy etc) Please list:
Do you have an existing diagnosis ADHD or Autism, or have you had a previous assessment? If yes please give details:
Please give a brief description of who you live with at home?
Please give a brief summary of your overall health and give details of any physical health issues?
Do you have a history of learning disabilities or difficulties at work? If yes please give details:
Do you have a history of learning disabilities or difficulties at work? If yes, please give details:
Do you have a history of mental health diagnosis or difficulties? If yes please give details:
Please list any medication for taken for mental health or physical health:
Who prescribes this medication GP, Hospital consultant or other?:
Have you experienced current or past trauma? Examples may include abuse domestic violence bereavement witnessing a traumatic event? If yes, please give details:
Do you use Alcohol, Tobacco or any recreational drugs? If yes, please give details:
Have you ever had any past or current involvement with the police or legal system (for example, as a witness, victim, or in any other capacity)? If yes, please provide details below:
Are there any current or historical safeguarding concerns? Examples include deliberate self-harm, suicidal behaviour, running away, exploitation or police involvement as above question? If yes, please give details:
Have you ever been in any situations where you 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:
Are you currently Pregnant, breastfeeding or planning a pregnancy?
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
Full diagnostic ADHD Report upload

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Consent to Assessment
Consent to Assessment Makewell Clinicians will explain each part of your 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 having an assessment at Makewell Clinic and understand that all assessment stages will be fully explained to me.
Your Name
Your Signature
Todays Date

DayMonthYear
Date
Privacy Notice
Your 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
Your Name
Your Signature
Todays Date

DayMonthYear
Date
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
Where did you hear about Makewell (if a partnership Pharmacy please confirm name of Pharmacy)
Cliniko Patient ID
Should be Empty:

Adult Self Referral Form

GP Information

Optional Additional Information

Additional Information

Consent to Assessment

Privacy Notice

Marketing Preferences