Autism and ADHD Service – Diagnostic assessment and medication review referral form

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Autism and ADHD Service - Diagnostic assessment and medication review referral form

Referral date(Required)

DD slash MM slash YYYY

Patient details

Name(Required)

Firstname Surname

NHS number(Required)

Date of birth(Required)

Gender(Required)

Male

Female

Prefer not to say

Address(Required)

Address line 1 Address line 2 Town County Postcode

Phone(Required)

Mobile

Email(Required)

Ethnicity(Required)

Other, please specify(Required)

Referrer details

Name(Required)

Firstname Surname

Referral source

Address(Required)

Address line 1 Address line 2 Town County Postcode

Phone

Email(Required)

GP details

Name

Surgery name(Required)

Surgery address(Required)

Address line 1 Address line 2 Town County Postcode

Phone

Email(Required)

Referral

Hidden

OLD - Type of referral

Please tick which of the following you are referring for and note the screening tools that must be completed & submitted with this referral form.

ADHD diagnostic assessment

ASD diagnostic assessment

ADHD review (existing diagnosis)

Hidden

OLD Type of referral

Please tick which of the following you are referring for and note the screening tools that must be completed and submitted with this referral form.

ADHD diagnostic assessment

ASD diagnostic assessment

ADHD review (existing diagnosis) - ASRS v1.1, diagnostic report, GP medical summary, cardiac questionnaire

Type of referral(Required)

Please tick which of the following you are referring for and note the screening tools that must be completed and submitted with this referral form. For an ADHD review referral, if you are unable to produce evidence of diagnosis with the referral, the patient will need to be referred for an ADHD diagnostic assessment.

ADHD diagnostic assessment - completed ASRS V5

ASD diagnostic assessment - completed AQ50

ADHD review (existing diagnosis) - ASRS V5, evidence of diagnosis (for example, diagnostic report, clinic letters) GP medical summary, cardiac questionnaire

Please tick if the patient has any of the following

Current symptoms of psychosis

Suspected/diagnosed personality disorder

Learning disability

Previous diagnosis of ASD

Previous diagnosis of ADHD

Hidden

OLD - If you ticked that the patient has an existing diagnosis of ASD and/or ADHD, please provide details of when this was diagnosed

Hidden

OLD - Please also attach copies of diagnostic reports or relevant clinic letters

Drop files here or

Max. file size: 50 MB.

If you ticked that the patient has a suspected/diagnosed personality disorder, please provide further details

For example, type of diagnosis, when and where they were diagnosed.

Hidden

OLD - Please also attach copies of diagnostic reports or relevant clinic letters

Drop files here or

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.

Hidden

OLD - Does the patient have any psychiatric history?

Please include any details of interaction with Mental Health Teams or hospital admissions.

Hidden

OLD - If the patient has a learning disability, please provide details

Hidden

OLD Does the patient have any forensic history?

The patient is currently in prison

The patient is currently under investigation by the police or awaiting a CPS trial or sentencing

None

Is the patient alcohol and/or drug dependant?

c) Is the patient currently being seen by a local mental health team, for example, CMHT, NHS Talking Therapies?

Risk and/or safeguarding concerns

Suicide

Self-harm

Self-neglect

Risk from others

Posing risk to others

Child protection

Current criminal justice proceedings

Forensic history

No risks or safeguarding issues

Please confirm that any risks identified above are being managed outside of this referral and if appropriate onward referrals have been made(Required)

Yes

Please provide details of any current safeguarding concerns, for example, family court /child protection, individual vulnerability abuse/neglect

Please provide details of any current criminal justice proceedings and indicate if this could be associated with possible ADHD/ASD symptoms

Hidden

OLD - Additional risk and/or safeguarding information

Hidden

OLD - Additional referral supporting information, not detailed above

ASD and/or ADHD diagnostic assessments

What has led to the patient seeking a referral for ASD/ADHD diagnostic assessment now?(Required)

What difficulties are being caused by apparent ASD/ADHD symptoms/behaviours (for example, problems in relationships, concentration at work)?(Required)

In what way does the patient hope to benefit from an assessment for autism/ADHD?(Required)

Hidden

OLD - Please attach a completed ASRS v1.1(Required)

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.

ASD diagnostic assessment

Please place a tick next to the option that best describes the patient.

Eye contact(Required)

Good

Fair

Poor

Engagement in conversation(Required)

Easy back and forth conversational flow

Conversation follows own interests with little listener awareness

Patient responds minimally to questions/does not offer information

Tone of voice(Required)

Appropriate variation in pitch and tone

Speech is somewhat monotone

Unusually loud or quiet at times

Is the patient dependent on family or friends for everyday tasks, for example, finance management, shopping etc?(Required)

Yes

Does the patient report having any sensory sensitivities?

None

Smell

Taste

Light

Textures

Sounds

In addition to yourself, has any other professional ever suggested the patient might have ASD?(Required)

Yes

Hidden

OLD - Please attach a completed AQ50

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.

ADHD review

When was the patient diagnosed with ADHD?(Required)

Please confirm that you would accept a Shared Care Agreement for this patient?(Required)

Yes

Is there a Shared Care Agreement already in place?(Required)

Yes

You do not need to refer to KCHFT, please refer directly to the provider whom you have the Share Care Agreement with.

Is the patient currently taking ADHD medication?(Required)

Yes

If yes, please provide the date this was last reviewed and by whom?(Required)

Hidden

OLD When was the patient last reviewed for ADHD and by whom?(Required)

Hidden

OLD Is the prescribing GP under a Kent & Medway (LES) shared care arrangement?

Please state reason for core service to undertake a review.

Hidden

OLD Who is the shared care arrangement between?

Provider name and GP details.

ADHD review or assessment

Please provide baseline measures.

Blood pressure(Required)

Pulse(Required)

Height(Required)

Weight(Required)

Reasonable adjustments

Any additional needs?

Support to complete additional written self-assessment documents

British sign language interpreter

Step free access/ground floor consulting room

Language translation

Longer appointment

None

Please detail any specific requirements

Attachments

Please attach relevant clinical correspondence and reports(Required)

Important information includes:
- current/past CMHT reports
- previous ADHD Assessment letters
- copies of previous involvement with the Child and Adolescent Service.

Drop files here or

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.

Please confirm the documents you have uploaded(Required)

ASRS V5

AQ50

Diagnostic report

GP medical summary

Cardiac questionnaire

Please note

If a referral is incomplete this will be rejected. The clinical team require sufficient information to enable them to complete the triage process.

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Autism and ADHD Service – Diagnostic assessment and medication review referral form

Your information

Autism and ADHD Service - Diagnostic assessment and medication review referral form

Patient details

Referrer details

GP details

Referral

ASD and/or ADHD diagnostic assessments

ASD diagnostic assessment

ADHD review

ADHD review or assessment

Reasonable adjustments

Attachments

Please note