ADHD Pre-Screen Questionaire
This brief screening helps determine whether our adult ADHD testing services are an appropriate fit.Our practice provides objective ADHD testing and a written summary only. This service does not include treatment, medication management, or ongoing care. Completion of this form takes approximately 2 minutes.
Name
*
First Name
Last Name
Email Address required
*
example@example.com
Are you 18 years or older? (Must be 18 or older and provide valid ID for testing
*
YES
NO
Are you seeking ADHD testing for treatment or medication from this practice?
*
YES
NO
Are you currently experiencing any of the following? (select all that apply)
*
Active suicidal thoughts
Recent psychiatric hospitalization (past 3 months)
Active psychosis or mania
Severe depression or anxiety currently untreated
None of the aboveype option 5
In the past 30 days, have you used any of the following? (select all that apply)
*
Non-prescribed stimulant medications(EX. Adderall}
Cocaine / methamphetamine
Daily cannabis use
Daily alcohol use
None of the above
What is the primary purpose of this testing?
*
Personal understanding
Requested by my medical provider
Documentation for my own records
College or professional exam accommodations
Please confirm the following (must select all):
*
I understand this service provides standardized testing and a written summary only
I understand this practice does not provide diagnosis, treatment, or medication
I understand results are intended to be reviewed with my own treating provider
Submit
Should be Empty: