Team of Therapists offering Psychology, EMDR & Counselling

Adults, Couples, Children & Families

Malvern, Worcestershire, UK

01684 877 115

Self Referral

contact@malvernhillsprivatepractice.co.uk

contact@malvernhillsprivatepractice.co.uk

ADHD Assessment – Self Referral Form

Please complete this form if you are 18 years or over, and would like to self refer for an ADHD Assessment.

 

 

The following form requests personal information. We take the privacy and security of personal data very seriously. This form is collected and processed in line with strict GDPR guidance. For further information please see our Privacy Policy and GDPR Policy Document.

Self Referral For ADHD Assessment v3

Client Information

Our ADHD assessments are presently only for adults. If you are 18 years or older, please complete this referral form yourself.
If you, the client, are 18 years or older please supply your own email address.
If you, the Client, are 18 years or older please supply your own mobile number.
We send your report to the GP so they can support you with ADHD treatment in the future (medication/ therapy)

Your ADHD Assessment

Remote ADHD Assessments are extremely accurate and valid, as many of the measures are computer based. However, if you require a face to face assessment (in Malvern) please specify:
Are you self-funding or is the fee being paid by Bupa Health Insurance?
We will be requesting information from other people. Please confirm you can supply the following:
Please tick all that you can supply

Our ADHD Assessment Process

Stage 1:You will receive an email containing a questionnaire which includes an ADHD Symptom Screen and Assessment Agreement. Once complete we will send you an invoice to pay for your assessment. Should your screen score be  too low to continue to Stage 2, we will contact you directly to discuss. If you are paying by Insurance we will also send you an Insurance Form. 

Stage 2: An email will be sent to you with a link to your ADHD pre assessment questionnaires. We will also send a separate email to your Childhood observer and Current Observer. Information from childhood is an extremely important part of the assessment. Without childhood information there is a risk the findings may be inconclusive. 

Stage 3: Once all questionnaires are completed, we will book you into two clinical interviews 90 mins + 60 minutes, usually conducted on the same day. Please speak to our secretary to ascertain availability of clinical interviews.  We operate on a first come basis, for clients who complete Stage 2. There is usually around a 2 week wait. 

QB Check Exercise: This is a researched based software program that measures attention, reaction time and impulsivity. It takes 30 minutes and compares scores to the same age and gender, with an estimate of your likelihood of ADHD. It is very helpful as an objective measure. Many clients find the results extremely interesting and validating as it demonstrates objectively struggles that they have felt internally for many years. If your case appears complex, (i.e. with different conditions present or missing information) a QB Check may be required; otherwise the outcome could be inconclusive. 

Fee: The initial fee for your ADHD assessment is £850, payable at the end of Stage 1. Should you want or require a QB Check this will be an additional £145. 

I confirm I have read the above Assessment Information and understand...
QB Check
For more information watch this video: https://vimeo.com/823723485/9d50951f54 or visit https://www.qbtech.com/.
If the outcome is unclear - I agree to a QB Check to gain additional information

Consent & Data Protection

Respecting your confidentiality and privacy is fundamental to our practice.
Your form will be stored securely in our password protected system and governed by strict GDPR rules. This form will be shared with your assessing Psychologist. We will not share your information outside of our practice unless (1) you have given us permission to share with an individual/ observer (2) your Health Insurance Provider request details, and (3) if you or a vulnerable other are in risk of harm, then we are legally obliged to report this concern to the relevant authorities and/ or your next of kin.
I consent to the storage and process of my information as described above.
For clients paying through Health Insurance:
How did you hear about our ADHD Assessments?

Next Steps

If your intentions are to pursue ADHD medication (with GP shared care)- we recommend speaking to your GP at the outset, so they are aware you are seeking support outside of the NHS.
Please allow 5 working days to get back to you. We will send an email with your Stage 1 Questionnaires.