Healthcare ADHD Assessment

Healthcare ADHD Assessment

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Non-binary Prefer not to state

Referral and Assessment Details

Assessment Components to be used (check applicable): Clinical interview Standardized rating scales Neuropsychological testing Collateral information (school/employer)

Insurance & Billing

Medical & Developmental History

Substance Use & Mental Health History

Educational / Occupational History

ADHD Symptom Checklist (DSM-5 style — past 6 months)

Inattention

Often fails to give close attention to details or makes careless mistakes
Often has difficulty sustaining attention
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish tasks
Often has difficulty organizing tasks and activities
Often avoids or is reluctant to engage in tasks requiring sustained mental effort
Often loses things necessary for tasks
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities

Hyperactivity / Impulsivity

Often fidgets or taps hands/feet, or squirms in seat
Often leaves seat in situations when remaining seated is expected
Often runs about or feels restless
Often unable to play or engage in leisure activities quietly
Is often "on the go" or acts as if "driven by a motor"
Often talks excessively
Often blurts out answers before questions have been completed
Often has difficulty waiting turn
Often interrupts or intrudes on others

Functional Impairment

Significant impairment currently present in (check all that apply): Home School Work Social relationships

Collateral / Informant Information

Prior Assessment & Treatment

Prior ADHD evaluation or testing? Yes No

Clinical Considerations, Risk & Limitations

I understand that the ADHD assessment will include a clinical interview, review of collateral materials, and standardized measures as indicated. I understand that diagnostic impressions are based on current information and that differential diagnoses (including mood, anxiety, learning disorders, substance use, or medical causes) will be considered. I acknowledge the limits of confidentiality (including duty to report imminent risk of harm to self or others, suspected abuse of a minor or dependent adult, and court-ordered disclosures) and understand that these limits may require disclosure of assessment findings.

Authorization to Release and Exchange Information (Optional)

I authorize the assessor to obtain and release relevant records and communications (e.g., school records, prior psychological or medical reports) as necessary for the assessment. I understand this authorization is voluntary and may be revoked in writing, except to the extent that action has already been taken in reliance upon it.

Statement of Fees & Scheduling

Fees for assessment components, cancellation and no-show policy, and billing arrangements will be provided separately. I acknowledge that I am responsible for fees not covered by insurance and that diagnostic reports are the property of the assessing clinician, subject to release as authorized above or as required by law.

Certification & Consent

By signing below I certify that the information I have provided is true and complete to the best of my knowledge. I consent to the ADHD assessment described above and understand the purpose, methods, risks, and limits of confidentiality associated with the assessment. I understand I may withdraw consent at any time, provided that withdrawal will not affect disclosures already made based on this consent.

I authorize the assessor to contact the persons and organizations noted in this form for collateral information and to release the assessment report to the parties listed above only as expressly authorized in writing.

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