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

Welcome to our ADHD Medication Service

We provide ADHD medication for patients 11 years* through to adulthood. Sessions are conducted remotely. Our fee structure is flexible and pay as you go:

Initial Medication Assessment (50 mins) – £295
Follow up every 3 to 4 weeks (25 mins) – £147.50
Prescriptions outside of appointments (£30)

Please allow at least 3 follow up appointments to fully stabilise dose and type of medication. The pharmacy will charge a fee for your private prescription to be filled (£70- £120 medication dependent). Our aim is to move you to Shared Care with your GP. Please note, children age 11 need to be secondary school age.

Patient Details

Are you completing this form on behalf of yourself, or for someone between 11 and 17 years old?

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

Preferred pronouns

he/him

she/her

they/them

Patient's date of birth

Patient's age

Patient's Address (first line)

Town

Post Code

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.

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)

[Essential] Please upload your FULL Clinical Assessment Report. A summary is not sufficient, we please need the full report. (If you were diagnosed by Malvern Hills Private Practice please leave blank).

Maximum file size: 12.58MB

PDF, DOC, DOCX . We can only progress your self referral if we have a copy of your full ADHD report.

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

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)

Please purchase a BP machine asap. Your pulse rate and blood pressure will be needed for your Health Screening Form.

(2) We will send you an email with a link to complete your 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

Welcome to our ADHD Medication Service

Patient Details

Your ADHD Assessment

Next Steps