ADULT ADHD REFERRAL FORM
THIS FORM IS TO BE COMPLETED BY THE PATIENT'S GP ONLY TO REFER PATIENTS TO ATROM MINDCARE UNDER PATIENT'S RIGHT TO CHOOSE . PATIENT CANNOT REFER THEMSELVES DIRECTLY.
Referral Date
*
-
Day
-
Month
Year
Date
PATIENT DETAILS
NHS Number
*
Date of Birth
*
-
Day
-
Month
Year
Date
Name
*
First Name
Last Name
Full Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred telephone number
Second telephone number
Gender
Male
Female
Prefer not to say
Other
Ethnicity
Email
*
Please note, your email address must be on an NHS domain (e.g. nhs.net).
REFERRER DETAILS
Please note, your email address must be on an NHS domain (e.g. nhs.net).
Referrer Name
*
First Name
Last Name
Referrer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Organisation
Referrer’s ICB name
*
Referrer’s Practice Code
*
Role in organisation
Contact Number(s)
Email
*
example@example.com
Has the patient consented to this referral?
*
Yes
No
Has patient consented to sharing their record data?
*
Yes
No
Any language barriers?
Yes
No
If yes, please give details as to what and how we could adjust for these:
Has the patient taken ADHD Screening Quiz (ASRS)
Yes
No
Please ask the patient to take ADHD Screening quiz(ASRS) on Atrom Mindcare website
GP DETAILS
GP Name
*
First Name
Last Name
GP Address
*
GP’s ICB name
*
GP’s Practice Code
*
Contact Number(s):
*
Email
*
example@example.com
REASONS FOR REFERRAL
Reasons for Referral
ADHD Diagnosis previously made?
*
Yes
No
Previous ADHD referral date
-
Month
-
Day
Year
Date
Patient currently on ADHD medication?
*
Yes
No
GOAL(S) OF REFERRAL
Goal(s) of Referral
In accordance to the NICE recommendation 1.7.29, after titration and dose stabilisation, prescribing and monitoring of ADHD medication should be carried out under Shared Care Protocol arrangements with primary care. Once patent is stabilised, our Consultant Psychiatrist work together with the patient’s GP for shared care arrangement. Would you (the GP) agree to shared care, post titration and dose stabilisation?*
*
Please Select
Yes
No
SUMMARY OF RISK
Suicide
Self harm/ Risk taking behaviours
Self neglect
Safeguarding
Risk to others / violent behaviour
Alcohol /Substance misuse
No identified risk
Other
Current/previous history of domestic abuse/violence?
Yes
No
Any children (living with patient) aged under 18 years?
Yes
No
Currently pregnant or up to 2 years post-partum?
Yes
No
Subject to Leaving Care Provisions?
Yes
No
RELEVANT MEDICAL, PSYCHIATRIC OR FORENSIC HISTORY
Please provide any Relevant Medical, Psychiatric or Forensic history. * ALL CARDIAC history must be noted as this will be required if titration with stimulant medication is considered. Please forward ALL history and recent ECG.
MEDICATIONS, ALLERGIES & MONITORING
Please send a print our of patient Medication history
Acute Medication (in the last 1 month)
Repeat Medication ** Please send a List if on any medication **
Allergies & Sensitivities
Monitoring
Rows
Date Last Measured
Result/Remark
Blood pressure
Pulse
Height
Weight
Blood Test
Submit
Should be Empty: