ADHD Medication - Self Referral Form - Psychology & Counselling- Therapists in Malvern for Adults, Couples & Children

Patient Details

Are you completing this form on behalf of yourself, or for someone between 11 and 17 years old? (We only see young people 11 + and adults for medication)

On behalf of myself, I am 18 years or older.

I am the parent/ carer of the patient who is between 11 and 17 years old. I have parental responsibility (please tick and add full name and relationship).I am the parent/ carer of the patient who is between 11 and 17 years old. I have parental responsibility (please tick and add full name and relationship).

Full name of patient

First

Last

Patient's date of birth

Patient's age

Preferred pronouns

Patient's email contact

Please put the direct contact for the patient, if the patient is 18 years or older. This may be used to check identity during the consultation. If the patient is between 11 and 17 years please use a parent/ carers details.

Patient's Mobile phone number

Please provide the mobile phone number for the patient, if the patient is 18 years or older. This may be used to check identity during the consult. If the patient is between 11 and 17 years please use a parent/ carers details.

Patient's Address (first line)

Town

Post Code

Your ADHD Assessment

Who undertook the original ADHD assessment?

A Psychologist within Malvern Hills Private Practice

A Psychologist on our ADHD Partner Program (please tick and add name)A Psychologist on our ADHD Partner Program (please tick and add name)

Unsure - if you are unsure, please contact your assessor to confirm they are a registered with our Partnership Program. If not, they are welcome to apply by emailing us directly.

When did this assessment take place? (mm/yy)

If your ADHD Assessment was undertaken outside of Malvern Hill Private Practice - Please upload your FULL Clinical Assessment Report. A summary is not sufficient, we please need the full report.

Maximum file size: 12.58MB

PDF, DOC, DOCX

If your document has been password protected, please email your password to contact@malvernhillsprivatepractice.co.uk (include the patient's full name)

I have emailed the password

My report is not password protected

GP Information

Accurate GP information is essential. We need to keep your GP up to date with the outcome of the Medication Assessment, and what drugs may be prescribed.

Who is your assigned GP? (please leave blank if unknown)

What is the name of your GP Practice?

What is the first line of your GP Practice address?

What the postcode of your GP Practice?

What is your NHS Number?

If you do not know, your GP Practice can tell you over the phone

What is the GP Practice email?

This may be on your GP Practice website. If not, please telephone your GP Practice and ask for their email address. If you cannot find their email at the time of completing this form please write "to follow" and tell us at a later date. Unfortunately we cannot book you into a Medication Assessment until we have your GP email. We need to keep your GP updated on your medication status.

Next Steps

(1) We require all patients to purchase a blood pressure monitor and regularly report on blood pressure and pulse rate. A UK NHS approved machine can be purchased from amazon.co.uk between £15 and £30.

I agree to monitor weight, blood pressure and pulse rate (using an NHS approved BP machine).

I agree to submit my readings prior to each follow up, by remembering to complete the Follow up Questionnaire.

Please purchase a BP machine prior to your first appointment for baseline measures. The schedule of monitoring will be discussed in the Medication Assessment.

(2) We will send you an email with a link to complete our Health Screening Form.

I will look out for the email

Please check your spam folder in case it lands there.

01684 877 115

ADHD Medication – Self Referral Form

Patient Details

Your ADHD Assessment

GP Information

Next Steps