ADHD: Online GP Referrals

PATIENT DETAILS

Patient First Name

Patient Last Name

Telephone

Patient's date of birth

Patient's address

Date of Birth

REFERRER DETAILS

Name of provider (GP or specialist)

Provider Number

Practice Name

Practice Email

Reason for referral

Relevant past medical and psych history

Upload any relevant medical documentation

Has patient previously been diagnosed with ADHD by psychiatrist or paediatrician?

Patient has been diagnosed with ADHD

Yes No

For how long would you like this referral to remain valid?

12 Months Indefinite

Authorisation Acknowledgment

Authorization Confirmation

I confirm that I am authorised as a medical practitioner to submit this referral for the patient

Important Notice: Authorised Use Only This form is strictly for use by the patient’s GP or other authorised medical practitioners only.
Any unauthorised use will be reported as a potential fraud incident.

ADHD: Online GP Referrals

This free ADHD screening test is designed for individuals who believe they might benefit from a more detailed ADHD evaluation.

SUBMIT YOUR DETAILS TO REVEAL RESULTS