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  • ADHD Referral Form

  • Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, please select an option that best describes how you have felt and conducted yourself over the past 6 months. You can save this form at any point or print the document once all questions have been answered.

  • 1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?*
  • 2. How often do you have difficulty getting things in order when you have to do a task that requires organization?*
  • 3. How often do you have problems remembering appointments or obligations?*
  • 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?*
  • 5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?*
  • 6. How often do you feel overly active and compelled to do things, like you were driven by a motor?*

  • Part A

  • 7. How often do you make careless mistakes when you have to work on a boring or difficult project?*
  • 8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?*
  • 9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?*
  • 10. How often do you misplace or have difficulty finding things at home or at work?*
  • 11. How often are you distracted by activity or noise around you?*
  • 12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?*
  • 13. How often do you feel restless or fidgety?*
  • 14. How often do you have difficulty unwinding and relaxing when you have time to yourself?*
  • 15. How often do you find yourself talking too much when you are in social situations?*
  • 16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?*
  • 17. How often do you have difficulty waiting your turn in situations when turn taking is required?*
  • 18. How often do you interrupt others when they are busy?*

  • Personal Statement

  • Your Chosen Provider

  • Please note: you must specify the clinic you would like to be referred to—this should not be answered 'Pendleside Medical Practice'.

     

    Unfortunately, we cannot process your referral without your chosen clinic or provider.

     

    For a full list of ADHD assessment providers under the Right to Choose scheme, please visit: https://adhduk.co.uk/right-to-choose/

     

    Please be aware that we are unable to select a provider on your behalf.

  • Private Provider Referral – Disclaimer and Acknowledgement

  • Dear Patient,

    You have the right to seek care from private healthcare providers, including under the NHS ‘Right to Choose’ pathway (e.g., for ADHD assessment or treatment). However, it is important to understand what Pendleside Medical Practice can and cannot do in relation to private care.

    Please read the following carefully before proceeding with a private referral.

    Tests and Investigations
    Pendleside Medical Practice is not obliged to arrange or carry out tests requested by a private provider, especially if:

    • The test falls outside the routine care we offer.
    • The interpretation of results is beyond our clinical expertise.

    Patients are advised to ensure that all investigations—especially those required before or after treatment—are arranged directly through the private provider.

    Medications

    We are not required to:

    • Prescribe medications recommended by private providers.
    • Convert private prescriptions to NHS prescriptions.

    However, if the medication is:

    • Within normal GP prescribing scope
    • Safe and suitable for general practice prescribing

    ...we may consider it on an individual basis and issue it according to our nonurgent
    prescribing timelines. If the medication is urgent, the private provider must supply it directly.

    Shared Care

    We cannot agree to shared care arrangements with private providers if any of the following apply:

    • No formal shared care agreement exists.
    • The agreement does not meet NHS standards.
    • The provider only assesses or diagnoses but does not prescribe.
    • Baseline tests, medication counselling, or suitability assessments are
      missing.
    • The patient has not been started, monitored, or stabilised on the
      medication.
    • The provider plans to discharge the patient to GP care without ongoing
      oversight.
    • The medication is outside our clinical competence or used off-licence.

    These rules protect patient safety. Without specialist oversight, we will not assume
    prescribing responsibility.

    Where none of the above issues apply, we may consider shared care requests on a case-by-case basis—this does not guarantee that care or prescriptions will be accepted.

  • Acknowledgement of Disclaimer

  • Should be Empty: