ADHD Screening CYP

ADHD Initial Screening – Children and Young People

Please complete the information below to support the assessment. Accurate and complete details will help us tailor the appropriate care and services.

Section 1: Child / Young Person Information

Full name of the child or young person:(Required)

Date of birth (DD/MM/YYYY):(Required)

Full home address:(Required)

GP name and practice details:(Required)

NHS Number (if known):

Parent/guardian names (with parental responsibility):(Required)

Contact telephone number:(Required)

Contact email address:(Required)

Section 2: Services Requested

Please indicate the services you are seeking (tick all that apply):

Section 3: Health & Developmental

BackgroundDoes the child/young person experience any of the following? (tick all that apply)

Please list any other medical or mental health conditions:(Required)

Are any other professionals currently involved in their care? If yes, please specify:(Required)

Section 4: Online Assessment Requirements

Most of our assessments are conducted online. To ensure this can be carried out effectively, please answer the following questions:

Do you have access to a laptop or computer with a webcam? (Tablets larger than 10" with a propping stand and webcam are acceptable. Phones are not permitted):(Required)

Do you have access to a reliable internet connection in a private setting?(Required)

Are you comfortable having the camera/webcam on for the full duration of the assessment?(Required)

Section 5: Clinical Risk Information

Is the child/young person homeschooled?(Required)

If not, please provide the school name and contact details:(Required)

Has the child/young person self-harmed in a way that required medical treatment?(Required)

Has the child/young person attempted to take their own life?(Required)

Has the child/young person expressed thoughts of suicide or feeling they would be better off not alive?(Required)

Has the child/young person engaged in high-risk behaviour? (e.g., substance use, theft, criminal activity)(Required)

Has the child/young person harmed another person, resulting in the need for medical attention?(Required)

Clinician Name(Required)

CAPTCHA

Cookie	Duration	Description
cookielawinfo-checkbox-analytics	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Analytics".
cookielawinfo-checkbox-functional	11 months	The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
cookielawinfo-checkbox-necessary	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
cookielawinfo-checkbox-others	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Other.
cookielawinfo-checkbox-performance	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Performance".
viewed_cookie_policy	11 months	The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.