Adult ADHD
& Autism

Service information and self-referral

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Right To Choose

What will happen next?

After completing this form, your GP practice will refer you to either your local ADHD/Autism Service or your preferred ADHD/Autism Right to Choose provider using the details you fill out below alongside information from your medical record.

Do I still need to book an appointment?

You do not need to book an appointment with a GP as you will be directly referred to the ADHD/Autism assessment service after completing this form. If you choose a Right to Choose provider that requires additional information the secretarial team will contact you.

How long are the waiting times?

We do not have access to waiting time data and please be aware that even the service provider may not be able to estimate the waiting time as this can vary depending on service conditions and the type of assessment that you require. Your waiting time may range from many months to multiple years depending on the conditions of the service.

Please select the referral you need

ADHD Self Referral
Autism Self Referral

ADHD Self-Referral Form

Required fields are marked with an asterisk (*).

Page 1 of 2

Name

First

Last

Date of Birth*

Mobile Number*

Email address*

Reason for referral*

Give us a comprehensive description of symptoms, background, impact on daily life and additional information

Initial Questions

1. Are you requesting Right to Choose – Yes or No drop downs*

2. If Yes please state which Right to Choose service you would like*

If other please specify

Please use the link below for further information regarding your ADHD/Autism Right to Choose providers. If you do not wish to proceed with a Right to Choose option and wish to be referred to your local service you do not need to select the Right to Choose option.

https://adhduk.co.uk/right-to-choose/

Please answer the questions below, stating which best describes how you have felt and conducted yourself over the past 6 months.

1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? *

2. How often do you have difficulty getting things in order when you have to do a task that requires organisation?*

3. How often do you have problems remembering appointments or obligations?*

4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?*

5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?*

6. How often do you feel overly active and compelled to do things, like you were driven by a motor?*

7. How often do you make careless mistakes when you have to work on a boring or difficult project?*

8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?*

9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?*

10. How often do you misplace or have difficulty finding things at home or at work?*

11. How often are you distracted by activity or noise around you?*

12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?*

13. How often do you feel restless or fidgety?*

14. How often do you have difficulty unwinding and relaxing when you have time to yourself?*

15. How often do you find yourself talking too much when you are in social situations?*

16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?*

17. How often do you have difficulty waiting your turn in situations when turn taking is required?*

18. How often do you interrupt others when they are busy?*

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

I consent to the practice collecting and storing my data from this form

Are you human?*

This field should be left blank

Autism Self-Referral Form

Required fields are marked with an asterisk (*).

Page 1 of 3

Name

First

Last

Date of Birth*

Mobile Number*

Email address*

Reason for referral*

Give us a comprehensive description of symptoms, background, impact on daily life and additional information

Initial Questions

1. Are you requesting Right to Choose – Yes or No drop downs*

2. If Yes please state which Right to Choose service you would like

For each statement below, choose one response that best describes how strongly that statement applies to you:

1. I prefer to do things with others, rather than on my own.*

2. I prefer to do things the same way over and over again.*

3. If I try to imagine something, I find it very easy to create a picture in my mind.*

4. I frequently get so strongly absorbed in one thing that I lose sight of other things.*

5. I often notice small sounds when others do not.*

6. I usually notice car number plates or similar strings of information.*

7. Other people frequently tell me that what I’ve said is impolite, even though I think it is polite.*

8. When I’m reading a story, I can easily imagine what the characters might look like.*

9. I am fascinated by dates.*

10. In a social group, I can easily keep track of several different people’s conversations.*

11. I find social situations easy.*

12. I tend to notice details that others do not.*

13. I would rather go to a library than to a party.*

14. I find making up stories easy.*

15. I find myself drawn more strongly to people than to things.*

16. I tend to have very strong interests, which I get upset about if I can’t pursue.*

17. I enjoy social chitchat.*

18. When I talk, it isn’t always easy for others to get a word in edgewise.*

19. I am fascinated by numbers.*

20. When I’m reading a story, I find it difficult to work out the characters’ intentions.*

21. I don’t particularly enjoy reading fiction.*

22. I find it hard to make new friends.*

23. I notice patterns in things all the time.*

24. I would rather go to the theatre than to a museum.*

25. It does not upset me if my daily routine is disturbed.*

For each statement below, choose one response that best describes how strongly that statement applies to you:

26. I frequently find that I don’t know how to keep a conversation going.*

27. I find it easy to ‘read between the lines’ when someone is talking to me.*

28. I usually concentrate more on the whole picture, rather than on the small details.*

29. I am not very good at remembering phone numbers.*

30. I don’t usually notice small changes in a situation or a person’s appearance.*

31. I don’t know how to tell if someone listening to me is getting bored.*

32. I find it easy to do more than one thing at once.*

33. When I talk on the phone, I’m not sure when it’s my turn to speak.*

34. I enjoy doing things spontaneously.*

35. I am often the last to understand the point of a joke.*

36. I find it easy to work out what someone is thinking or feeling just by looking at their face.*

37. If there is an interruption, I can switch back to what I was doing very quickly.*

38. I am good at social chitchat.*

39. People often tell me that I keep going on and on about the same thing.*

40. When I was young, I used to enjoy playing games involving pretending with other children.*

41. I like to collect information about categories of things (e.g. types of cars, birds, trains, plants).*

42. I find it difficult to imagine what it would be like to be someone else.*

43. I like to carefully plan any activities I participate in.*

44. I enjoy social occasions.*

45. I find it difficult to work out people’s intentions.*

46. New situations make me anxious.*

47. I enjoy meeting new people.*

48. I am a good diplomat.*

49. I am not very good at remembering people’s date of birth.*

50. I find it very easy to play games with children that involve pretending.*

Privacy Consent

I consent to the practice collecting and storing my data from this form

Are you human?*

This field should be left blank

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Adult ADHD
& Autism

Right To Choose

What will happen next?

Do I still need to book an appointment?

How long are the waiting times?

Please select the referral you need

ADHD Self-Referral Form

Initial Questions

Please answer the questions below, stating which best describes how you have felt and conducted yourself over the past 6 months.

Autism Self-Referral Form

Initial Questions

For each statement below, choose one response that best describes how strongly that statement applies to you:

For each statement below, choose one response that best describes how strongly that statement applies to you:

ADHD & Autism Resources

Register as Patient

More Self-Referral and Review Forms

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