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ADHD
For children
How to request an assessment What to expect at an assessment Combined assessments ADHD FAQS Screening appointment
For adults
How to request an assessment What to expect at an assessment Combined assessments ADHD FAQs Screening appointment
Autism
For children
How to request an assessment What to expect at an assessment Combined assessments Autism FAQs Screening appointment
For adults
How to request an assessment What to expect at an assessment Combined assessments Autism FAQs Screening appointment
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Autism
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ADHD
ADHD
- For children
  For children
  How to request an assessment What to expect at an assessment Combined assessments ADHD FAQS Screening appointment
- For adults
  For adults
  How to request an assessment What to expect at an assessment Combined assessments ADHD FAQs Screening appointment
Autism
Autism
- For children
  For children
  How to request an assessment What to expect at an assessment Combined assessments Autism FAQs Screening appointment
- For adults
  For adults
  How to request an assessment What to expect at an assessment Combined assessments Autism FAQs Screening appointment
Services
Services
NHS Right to Choose
About
About

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This form is for GP use only. This is for an application to Evolve Psychology Services for an ADHD only, autism only or a combined autism and ADHD assessment through NHS Right to Choose.

Evolve currently offer NHS Right to Choose autism and ADHD assessments
for children up to age 19 (assessment has to start before their 19th birthday). We
only offer autism assessments for adults on the NHS Right to Choose pathway.
Click next to fill in the referral details. Please put in as much detail as possible, thank you.

Any queries about the process please contact us at [email protected] or
01423 637818

Is your patient:*
Under 19Over 19

Name of GP referring
First NameLast Name
Practice address
Street Address
Street Address Line 2
CityCounty
Postcode
Practice email
[email protected]
Practice telephone number
Practice code
ICB
Patient name
First NameLast Name
Patient NHS number
Patient DOB
MonthDayYear
Patient address
Street Address
Street Address Line 2
CityCounty
Postcode
Parent/Carer Name
First NameLast Name
Parent/Carer address (if same as patient address put ‘same as above’)
Street Address
Street Address Line 2
CityCounty
Postcode
Parent/Carer email address
[email protected]
Parent/carer telephone number
Relationship to patient
Parent/carer primary language
Assessment requesting:
Autism onlyADHD onlyAutism and ADHD combined
Give reasons for your request of this assessment (e.g for ADHD the patient may present with inattention and higher levels of activity or for autism they may report social communication difficulties, need for routine or sensory sensitivities)
Does your patient have a first language that is not English?
YesNoDon't know
Please provide more information
Is your patient under 7 years old?
YesNoDon't know
Please provide more information
Does your patient have an intellectual disability or diagnosis of global developmental delay?
YesNoDon't know
Please provide more information
Is your patient preverbal (non speaking)?
YesNoDon't know
Please provide more information
Does your patient have a head injury or neurological condition which has left them with significant cognitive impairment?
YesNoDon't know
Please provide more information
Does your patient currently pose a risk to themselves or others?
YesNoDon't know
Please provide more information
Is your patient currently receiving treatment with CAMHS?
YesNoDon't know
Please provide more information
Is your patient known to the justice system, either now or previously to your knowledge?
YesNoDon't know
Please provide more information
Has your patient had involvement from safeguarding services?
YesNoDon't know
Please provide more information
Has your patient had any recent admissions to acute mental health inpatient services?
YesNoDon't know
Please provide more information
Are there any other concerns around your patient’s mental health?
Has your patient recently self-harmed or has suicidal ideation?
YesNoDon't know
Please provide more information
Has your patient recently self-harmed requiring medical attention?
YesNoDon't know
Please provide more information
Has your patient had any recent involvement with drug or alcohol services?
YesNoDon't know
Please provide more information
Has your patient had any recent history of disordered eating?
YesNoDon't know
Please provide more information
Does your patient have a history of psychosis or had a recent psychotic episode?
YesNoDon't know
Please provide more information
Does your patient have a hearing or visual impairment that would prevent access to be able to see the resources / hear the clinician?
YesNoDon't know
Please provide more information
Any other known disability
Any medical information that would be beneficial for us to know
Are they currently on a CAMHS or NHS waiting list?
YesNoDon't know
Please provide more information
Please attach any relevant reports, letters or screenings, for example reports from paediatrician, speech and language therapist, occupational therapist.
Cancelof

Name of GP referring
First NameLast Name
Practice address
Street Address
Street Address Line 2
CityCounty
Postcode
Practice email
[email protected]
Practice telephone number
Practice code
ICB
Patient name
First NameLast Name
Patient NHS number
Patient DOB
MonthDayYear
Patient address
Street Address
Street Address Line 2
CityCounty
Postcode
Patient telephone number
Assessment requesting: please note we only do autism only for adults on NHS Right to Choose
Autism only
Give reasons for your request of this assessment (e.g the patient may report social communication difficulties, need for routine, or sensory sensitivities)
Parent/carer name if patient requires support to access this assessment
First NameLast Name
Parent/Carer address (if same as patient address put ‘same as above’)
Street Address
Street Address Line 2
CityCounty
Postcode
Parent/Carer email address
[email protected]
Parent/carer telephone number
Relationship to patient
Parent/carer primary language
Does your patient have a first language that is not English?
YesNoDon't know
Please provide more information
Does your patient have an intellectual disability or diagnosis of global developmental delay?
YesNoDon't know
Please provide more information
Is your patient preverbal (non speaking)?
YesNoDon't know
Please provide more information
Does your patient have a head injury or neurological condition which has left them with significant cognitive impairment?
YesNoDon't know
Please provide more information
Does your patient currently pose a risk to themselves or others?
YesNoDon't know
Please provide more information
Is your patient known to the justice system, either now or previously to your knowledge?
YesNoDon't know
Please provide more information
Has your patient had involvement from safeguarding services?
YesNoDon't know
Please provide more information
Has your patient had any recent admissions to acute mental health inpatient services?
YesNoDon't know
Please provide more information
Is your patient currently receiving treatment for their mental health?
YesNoDon't know
Please provide more information
Are there any other concerns around your patient’s mental health?
Has your patient recently self-harmed or has suicidal ideation?
YesNoDon't know
Please provide more information
Has your patient recently self-harmed requiring medical attention?
YesNoDon't know
Please provide more information
Has your patient had any recent or active involvement with crisis / home based treatment services?
YesNoDon't know
Please provide more information
Has your patient had any recent involvement with drug or alcohol services?
YesNoDon't know
Please provide more information
Has your patient had any recent history of disordered eating?
YesNoDon't know
Please provide more information
Does your patient have a history of psychosis or had a recent psychotic episode?
YesNoDon't know
Please provide more information
Does your patient have a hearing or visual impairment that would prevent access to be able to see the resources / hear the clinician?
YesNoDon't know
Please provide more information
Any other known disability
Any medical information that would be beneficial for us to know
Are they currently on an NHS waiting list for this assessment?
YesNoDon't know
Please provide more information
Please attach any relevant reports, letters or screenings, for example reports from paediatrician, speech and language therapist, occupational therapist.
Cancelof

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