Eligibility Questionnaire

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Eligibility Questionnaire

Email *

Admin - Please provide your name (the person to be assessed) *

Admin - Please provide your date of birth (the person to be assessed) *

Admin - Please provide the email address you wish to use for this assessment process *

Admin - Please provide the phone number you wish to use for this assessment process *

Admin - Do you have any additional needs which I can take into account to help you with the assessment process? (if yes, please describe)

The assessment will require information from someone who is able to give their observations of your presentation during childhood.

Please enter their name, email and phone number below

The assessment will require information from someone who is able to give their observations of your presentation during adult hood - specifically the last 6 months. This could be a partner, older sibling, teacher or work colleague.

Please enter their name, email and phone number below

Admin - If the person to be assessed is under 18 years old, please provide details of the adult providing consent for this assessment. (contact details if different from above, relationship to the patient).

Admin - CONSENT DECLARATION

I understand that the answers given here will be used to screen for eligibility for an ADHD assessment. I will be truthful and not over or under exaggerate any symptoms. I understand that doing this may provide an inaccurate picture of my presentation and could jeopardise the full assessment.

The patient (over 18yrs old)

The adult providing consent (for patient under 18yrs old)

Required

Question - How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? *

Never

Rarely

Sometimes

Often

Very Often

Question - How often do you leave your seat in meetings or other situations in which you are expected to remain seated? *

Never

Rarely

Sometimes

Often

Very Often

Question - How often do you have difficulty unwinding and relaxing when you have time to yourself? *

Never

Rarely

Sometimes

Often

Very Often

Question - When you are in a conversation, how often do you find yourself finishing the sentences of the other people before they can finish it themselves? *

Never

Rarely

Sometimes

Often

Very Often

Question - How often do you put things off until the last minute? *

Never

Rarely

Sometimes

Often

Very Often

Question - How often to you depend on others to keep your life in order and attend to details? *

Never

Rarely

Sometimes

Often

Very Often

Progress - If you are eligible for an ADHD assessment, how would you like to pay?

The cost is £700.

If you (or the person funding any assessment) are currently not working, we can consider a payment arrangement (proof required of any benefits etc)

Progress - If you are eligible for an assessment, when would be the best times for an assessment consultation?

These sessions need uninterrupted time of 2 hours and are conducted on video platform;

You will need stable internet in quiet and private space to be able to talk openly without distraction.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Mornings (1030am-1230pm)

Afternoons (2pm-4pm)

Evenings (6pm-8pm)

Other:

Send me a copy of my responses.

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