ADULT ADHD ASSESSMENT AGREEMENT

Title:

Tel:

Name:

Consent to contact you by phone:

Email:

Consent to leave voicemail:

Date of Birth:

Do you want anyone to be copied in on all emails to support you with the paperwork for the assessment?

Yes

If Yes please provide details below

Name:

Email:

How would you like to be named in the report eg.First name (eg Lucy) Or surname, (eg Ms Smith):

Address:

Post Code:

Please confirm your consent:

I use secure online systems, which meet GDPR to store and process data. Please see the Privacy Policy for further information:

Medical Information

GP Surgery Name and Address:

GP Surgery Phone Number:

If you are diagnosed with ADHD, is your GP willing to enter into a “Shared Care Agreement” with a Specialist Private Prescriber?

I strongly advise you to discuss with your GP your intention to have a private ADHD assessment before booking the assessment.

If a person receives an ADHD diagnosis, even if they go privately for medication assessment, most people want their GP to prescribe the medication once it has been stabilised. It is therefore very important that the GP is supportive of a private assessment, is willing to enter into a “Shared Care Agreement” with a private prescriber and that any questions or concerns can be addressed at the outset. If this is not the case, you would have to pay permanently for your own prescriptions.

High Blood Pressure?

Cardiac problems?

Thyroid problems?

Epilepsy?

Hypermobility:

Respiratory problems?

Diabetes?

Any other medical conditions? If “yes” please give details below:

Other Medical Conditions if the answer was Yes above:

Does anyone in your family have a history of heart problems?

Does anyone in your family have a history of high blood pressure?

School Reports

Do you have school reports available?

If you have your school reports or other assessment reports from childhood or recently, e.g. psychiatric reports, Dylsexia or Autism Assessment reports, please upload opposite.

Other Reports:

4-6 Years:

7-9 Years:

9-11 Years:

12-14 Years:

14-16 Years:

16-18 (if still at school):

Other Participants

Someone who knew you well as a child, who is at least 7 years older than you, who has given permission for me to contact them, to participate in your assessment:

Title:

Name:

Email:

Tel:

Relationship to you e.g. mother, father, aunt:

If you do not have anyone you can or want to ask who knew you well as a child, you can ask someone who knows you well as an adult

I ONLY NEED TO SPEAK TO EITHER SOMEONE WHO KNEW YOU AS A CHILD OR SOMEONE WHO KNOWS YOU AS AN ADULT, NOT BOTH.

Someone who knew/knows you well as an adult, who has given permission for me to contact them, to participate in your assessment:

Title:

Name:

Email:

Tel:

Relationship to you e.g. partner, friend, supervisor, manager:

Cost of an assessment

The fee for an assessment is £895 and includes questionnaires, the online assessment appointment including a conversation with your informant, a comprehensive Assessment Report and the post-assessment follow-up appointment.

Cancellation of Assessment Appointment

If you cancel the appointment with more than 7 days’ notice, there is a £150 cancellation fee.

If you cancel with less than 7 days’ notice there is a £250 cancellation fee.

Cancellation of Follow Up Appointment

If you cancel the follow-up appointment with less than 48 office hours’ notice, there is a £50 cancellation fee.

Payment to be made by bank transfer to:

Account Name: Jennifer Susan Arthern

Account Number: 65860873

Sort Code: 40-47-67

Your appointment will be confirmed when payment and your completed Agreement form have been received.

Disclaimer

The outcome of an ADHD Assessment

The outcome of the ADHD assessment may be a diagnosis of ADHD or a decision that you do not have ADHD. You are paying for an assessment and not for a diagnosis. Even when the assessment has been recommended by Jenny Arthern, following a screening appointment, or by another professional, there is no guarantee that you will receive a diagnosis of ADHD.

Medication

There is no consultation regarding medication included in the cost of your ADHD assessment, and you are responsible for arranging this if you require it. Some services including the NHS, universities or workplaces may wish to reassess you before prescribing medication or making reasonable adjustments and this is often dependent on where you live and on local GP and/or NHS Trust policies. You are advised to consult with your GP regarding local policies and procedures before booking an ADHD Assessment.

Implications of an ADHD diagnosis

An ADHD diagnosis may exclude you from certain careers and opportunities, such as obtaining a pilot’s license or joining the army and it may have implications regarding health insurance. This list is not exhaustive, and the onus is on you to explore this before seeking an assessment. The ADHD assessment is not a legal document and cannot be used in court.

I have read the above information and would like to book an ADHD Assessment with Jenny Arthern, HCPC Registered Psychologist.

Name of Applicant:

Today's Date:

Please confirm:

I consent to this agreement

The Adult ADHD Assessment includes:

An online assessment appointment, lasting a maximum of 2.5 hours including a mid-session break of 15 minutes, to provide information about yourself.

The opportunity for someone who knew you well as a child to provide information to me in a phone call and to complete a questionnaire. Alternatively you can ask someone who knows you well as an adult to provide information to me and complete a questionnaire

A comprehensive Assessment Report with a copy for you and for your GP.

A letter confirming the diagnosis (if it is a positive diagnosis).

A 30-minute appointment after the Assessment Report has been completed to discuss the outcome of the assessment and to support you to access treatment and therapy options depending on the diagnosis.

Criteria for the diagnosis of Adult ADHD

For a diagnosis of ADHD to be made, symptoms should:

meet the diagnostic criteria in The Diagnostic and Statistical Manual of Mental Health Disorders V

the symptoms of hyperactivity/impulsivity and/or inattention need to cause at least moderate psychological, social and/or educational or occupational impairment based on interview and/or direct observation

be pervasive, occurring in 2 or more important settings including social life, family, school or work settings

Confidentiality

Like all psychologists I am required to have regular clinical supervision and may take to supervision anything which we discuss in your assessment. The aim of supervision is to ensure that I provide the most effective service for you.

In very rare instances (such as information relating to terrorism) I may be required by law to disclose confidential information about you.

I may contact your GP or other professionals involved in your care if I believe that there is a risk of serious harm to yourself or others. This includes issues relating to the safeguarding of children and vulnerable adults.

I am registered with the Information Commissioner’s Office, and I understand General Data Protection Regulation and abide by this for the storage of all data. Information held digitally is encrypted.

Professional Registration

I am registered with the Health and Care Professions Council (HCPC). If you have a complaint against me which it has not been possible for us to resolve through discussion, then please contact HCPC:

Tel: 0800 328 4218 Email: ftp@hcpc-uk.org