ADHD Medication - Self Referral Form

Please complete this form if you already have a diagnoses of ADHD and you would like to book with our Independent Prescriber to consider ADHD Medication. Please note, this service is remote and available for adults and young people from 11 years and older.

The ADHD diagnosis must have been made by a Psychologist within Malvern Hills Private Practice (MHPP) or by a Psychologist registered to our Partnership Program.

The following form requests personal information. We take the privacy and security of personal data very seriously. This form is collected and processed in line with strict GDPR guidance. For further information please see our Privacy Policy and GDPR Policy Document.

Self Referral for ADHD Medication

Patient Details

Are you completing this form on behalf of yourself, or for someone between 11 and 17 years old? (We don't presently see children age 10 or younger for ADHD medication)

On behalf of myself, I am 18 years or older.

I am the parent/ carer of the patient who is between 11 and 17 years old. I have parental responsibility (please tick and add full name and relationship).I am the parent/ carer of the patient who is between 11 and 17 years old. I have parental responsibility (please tick and add full name and relationship).

Full name of patient

First

Last

Patient's date of birth

Patient's age

Patients NHS Number

Patient Home Address

Best email contact

Mobile phone number

Name of GP

GP/ Practice Email (Essential to copy your GP into your medication status)

This may be on your Practice website, or you may need to call them to find out

GP Address

Your ADHD Assessment

Who undertook the original ADHD assessment?

A Psychologist within Malvern Hills Private Practice

A Psychologist on our ADHD Partner Program (please tick and add name)A Psychologist on our ADHD Partner Program (please tick and add name)

Unsure - if you are unsure, please contact your assessor to confirm they are a registered with our Partnership Program. If not, they are welcome to apply by emailing us directly.

What was the approximate date of this assessment?

If your ADHD Assessment was undertaken outside of Malvern Hill Private Practice - Please upload your Clinical Assessment Report

Maximum file size: 2.1MB

PDF, DOC, DOCX

If your document has been password protected, please email your password to contact@malvernhillsprivatepractice.co.uk (with your full name in the header)

Medication Assessment Consent

Please read in full V18.03.24

What is a Medication Assessment?
It is a consultation lasting up to 50 minutes where our Prescribing Pharmacist (Mr Bolu Abifarin) will discuss the option of ADHD medication. A 30 minute follow up appointment will be made for three weeks time. A prescription is only given for 30 days so you must attend each follow up to discuss side effects and whether the dose and preparation type is suitable for you.

Professional Accountability
Our pharmacist is fully trained and experienced in providing ADHD medication. He is presently employed in an NHS ADHD medication service. He is fully insured and DBS checked. He also has access to a psychiatrist to discuss complex cases. For more details on our Prescribing Pharmacist please see his bio on our website.

Personal Data
Please see our detailed page on how we store and use your personal data GDRP Policy Document.

Complexity
On rare occasions, the Medication Assessment (or Follow-ups) may reveal your case to be complex. We attempt to screen for this using our Health Screening Form. However, if this occurs, we may signpost you to a Psychiatrist. This will be outside of our practice and will incur additional fees set by the Psychiatrist in private practice.

Confidentiality
Your clinical notes and therapy attendance are held within the team. Your Prescriber has a duty of care that means that if they have concerns about your safety or that of a vulnerable adult or child, they will disclose limited information of this concern to your next of kin and other services (i.e. GP/ safeguarding team). The concern may also be discussed with other therapists within the team.

Your Prescriber may also disclose information if they are legally obliged, or if a serious crime has taken place, especially if others are still at risk (i.e. the perpetrator still has contact with vulnerable adults or children).

Your Prescriber will aim to discuss all safety concerns with you first, before disclosing information to others, although this is not always possible.

If someone else is paying for your sessions, or has provided card details to our system (i.e. a family member, friend or a company) and they enquire about your attendance, we may provide limited information pertaining to which sessions have been attended/ missed.

It is agreed that neither party will record any of the sessions with any type of recording device unless written prior agreement of both parties has been given. For further details, please see our Privacy Policy.

Cancellation Policy
Please give your Therapist at least 24 hours’ notice if you need to cancel or change an appointment by texting their mobile which is on your Confirmation Email. If an appointment is cancelled in under 24 hours a half fee is charged.

Please note insurance do not pay for missed or cancelled sessions. These will be charged to the stored card, as per your Insurance Agreement. In the case of any fee disputes, we may need to provide evidence to your bank of this therapy agreement.

Assessment & Reports
We reserve the right to decline a Medication Assessment/ Treatment if we are not satisfied with the assessment or report provided (with specific reference to how comprehensive the assessment appears and the differential diagnosis considered). In this instance we may contact the assessor for further information, or request a repeat assessment.

If, during the Medication Assessment, the diagnoses of ADHD becomes in question we may request a repeat assessment prior to any medication being provided or we may signpost you to a Psychiatrist for further assessment.

Shared care
Once your dose has been optimised, we will write to your GP to request shared care. This is where the NHS take over monthly prescriptions for your medication. However shared care is at the discretion of your GP, and not all GPs are comfortable agreeing to shared care. We suggest you speak with your GP about this prior to seeing our Prescriber.

If your GP declines shared care, our Prescriber could continue to provide medication at the cost of £30 for writing a prescription per month. There will also be the fee from the pharmacist for the medication itself.

Consent for a Medication Assessment (V18.03.24)

I have read in full and agree to the terms of the Medication Assessment

Please contact us directly if you are unsure of any points outlined above.

Next Steps

(1) We require all patients to purchase a blood pressure monitor and regularly report on blood pressure and pulse rate. A UK NHS approved machine can be purchased from amazon.co.uk between £15 and £30.

I consent to self-monitoring weight, blood pressure and pulse rate (using an NHS approved BP machine).

Please purchase a BP machine prior to your first appointment for baseline measures. The schedule of monitoring will be discussed in the Medication Assessment.

(2) We will send you an email with a link to complete our Health Screening Form and Baseline Symptoms Measure.

I will look out for the email

Please check your spam folder in case it lands there.

If you are human, leave this field blank.

ADHD Medication – Self Referral Form

Patient Details

Your ADHD Assessment

Medication Assessment Consent

Next Steps