ADHD Referral Questionnaire

Last Updated: 09/10/2024

About You

Please complete the “About You” section and the relevant questionnaire/s in this pack for ADHD, Autism or both, along with the Problem Shared Suitability Criteria if you want to be referred to that service

PLEASE NOTE
If you don't have access online, or you struggle to complete any of the above, then please talk to reception who can arrange an appointment with a clinician, for you to discuss your symptoms. Please note, there may be a wait for an appointment











Adult ADHD Self Report Scale Part A

Please answer the questions below, rating yourself on each of the criteria shown using the answers provided. As you answer each question, please tick the box that best describes how you have felt and conducted yourself over the past 6 months. 







Adult ADHD Self Report Scale Part B













Problem Shared Suitability Criteria

If no service is selected you will be referred to the local service which has a 5+ year wait.   If you have selected ProblemShared please ensure you complete the exclusion criteria. If you have not answered this we will not be able to refer you.

You or your child are not suitable for an online assessment with ProblemShared at this time if any of the following statements apply to you:



















Questionnaire Completion

If you meet the eligibility criteria, we will refer you onto your chosen service. You will be notified via SMS message to let you know that we have sent the referral, or if you don't meet the criteria.  

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