Please complete the Child/ Younger Person ADHD Referral below. This will be sent on to our Secretaries for processing.

Please note. once the referral has been sent off by Carlisle Healthcare, there is an extensive waiting list at North Cumbria Attention Deficit Hyperactivity Disorder (ADHD) Children and Young People’s Service. 

They are unable to give a time frame for assessments however are working through referrals in the order they have been received, and will contact patients by letter when they are ready to start the assessment.

This form is only to be completed by patients who have received a direct text message link from our Secretaries.

If you have not received a text link, your form will not be processed. 

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CHILD/ YOUNG PERSON'S DETAILS
 
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PARENT/ CARER DETAILS

Parent/ Guardian 1.

Parent/ Guardian 2.

 
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SCHOOL/ COLLEGE DETAILS
OTHER PROFESSIONAL DETAILS
 
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HYPERACTIVITY DIFFICULTIES INFORMATION
Please see attached DSM-5 Appendix PDF file prior to answering questions

APPENDIX FILE

 
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CONFIRMATION

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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