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)

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