ADHD Self-Referral Form

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Quick check before you fill out the form

Please screen yourself with this questionnaire before filling out the rest of the form.

Please tick all that applies to you *

My life currently feels hard because of low mood, anxiety or trauma symptoms.I have previously been under public mental health services.I have current thoughts to harm myself.I have a history of heart attacks, strokes, other heart conditions, or my quality of life is currently affected by physical health issues.I do not currently have a GP.I drink more than 15 standard drinks of alcohol a week (for men) or 10 standard drinks a week (for all others).In the last two years, I have used recreational substances, including cannabis, MDMA, LSD, psilocybin, ketamine, opioids, methamphetamine, or cocaine.None of the above applies.

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ASRSscore2 *

I have fully filled out the brief screening questions above. *

Hold on a minute!

Our brief screen shows that you should see your GP for a referral first.

It doesn't mean that you do not have ADHD, but a triage with your GP ensures it is worth your time and effort to come see us. As soon as we receive a referral from your GP we will be in touch with the next steps.

If you are currently experiencing severe mental health symptoms, or are experiencing thoughts of suicide, please contact 0800 920 092 in Canterbury, or your local Crisis Mental Health team.

Thank you for completing the screening. Please continue with the self-referral form

If you are currently experiencing severe mental health symptoms, or are experiencing thoughts of suicide, please contact 0800 920 092 in Canterbury, or your local Crisis Mental Health team.

Personal Details

First Name *

Middle Name

Last Name *

Preferred Name

Pronouns (if you wish to specify)

Date of Birth *

Age

Phone number (cellphone preferred) *

Street address *

Suburb *

City *

Postcode

General Practice

Name of your General Practice Prescriber / Doctor

Name of your General Practice *

Emergency Contact

Full Name *

Relationship to you *

Phone Number *

Do you have Southern Cross Insurance? (for any other insurers, please tick no) *

YesNo

Member or Policy number (Southern Cross only) *

Medical Information

Please tell us about how we can help (a few sentences, or a paragraph) *

If not answered already, can you help us understand why you are wondering about whether ADHD is contributing to your difficulties

Medical History

Please tick all conditions that might apply to you *

High blood pressure / hypertensionHigh blood sugars / diabetesLung issues (such as asthma)Heart issues (such as history of heart attacks, or abnormal rhythms)Seizures or epilepsyNone of the above

If you have other medical conditions that you take medications for, or currently impact on your quality of life, please give us some information about them below

Please list current medications and supplements (regularly and as needed, include dose if you know)

Previous Mental Health Care

Are you currently under, or have you previously been under the care of another mental health service, either public, private, or ACC? *

YesNo

Please let us know which services are currently or previously have been involved with your mental health care *

What are the diagnoses you have been given? *

Have you, or any health professionals suspected you may have psychosis, schizophrenia, mania, or bipolar disorder? *

What to expect from here

1. After submitting this form, your referral will be promptly triaged.

2. If accepted, you will receive an email that has a link for you to book in at a time that suits you.

3. We will actively send reminders to ensure you remember to book. We will also email your GP to let them know of this self-referral.

4. You will pay a 30% deposit, and fill out some forms. The rest of the cost will be due 24 hours after your first appointment.

For Southern Cross members please look at the booking link in the email and let us know what time might work for you, so that we can manually book you in and then claim on your behalf after the appointment.

Upon submitting the form, your personal details will be sent securely to Ōtautahi Clinic.

Tick below if you:

- Have reviewed the privacy policy of Ōtautahi Clinic.

- Consent for us to view your HealthOne (electronic health) records to help us triage your referral.

- Consent for us to notify your GP of this self-referral and to communicate openly with them about relevant clinical information.

I have reviewed the privacy policy and I consent. *

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