NHS ADHD Referral Form – LaTahzan CRM

GP Details

Details of the GP completing this form

GP First Name

GP Last Name

GP Practice Address

Address Line 1

Address Line 2

City

Post Code

GP Phone/Mobile

GP Email Address

Current Integrated Care Board (ICB)

Other ICB

Patient Details

Details of the patient who to be referred for ADHD assessment.

Patient’s First Name

Patient’s Last Name

Patient’s Date of Birth

Patient’s Biological Sex

Patient’s NHS Number

Patient’s Address

Address Line 1

Address Line 2

City

Post Code

Patient’s Phone/Mobile

Patient’s Email

ADHD Self-Report

The Adult ADHD Self-Report Scale (ASRS) is mandatory for all ADHD referrals. Patient can complete our online form by Clicking Here.

Patients can also download and complete a paperform of the ASRS by Clicking Here.

Adult ADHD Self-Report Scale v1.1 (ASRS)

ASRS Submission Number on LaTahzan Centre

Please upload a scanned copy of the completed ASRS in a paperform

Upload PDF / Image Files

Medical History

Relevant medical history of the patient.

Please upload any relevant medical history of the patient

Upload PDF / Image Files

Any further information

Confirmation

Some description about this section

By completing this form, I am requesting that my patient, , be referred to LaTahzan Centre for an ADHD Assessment under the NHS Right to Choose Legislation.

GP Signature

Sign Here