Adult ADHD NHS Referral Form – Chelmsford Health Centre

📋 Adult ADHD NHS Referral Form

Please send completed forms to: referrals@chelmsfordhealthcentre.com | Or post to: Chelmsford Health Centre, Dickens Place, Chelmsford, Essex CM1 4UU
Note: We only accept NHS Right to Choose referrals from GPs who agree to shared care for ongoing medication management.

1. Patient Details

Full Name

Date of Birth (DD/MM/YYYY)

Address (first line & postcode)

NHS Number (if available)

Contact Telephone

Email Address

2. Referring GP / Clinician

Clinician Name

Practice Name

Practice Email

Practice Telephone

3. Clinical Information

Key Presenting Concerns (tick all that apply)

Reason for referral / relevant history (optional — full history taken at assessment)

4. Safety & Medication

Current psychiatric medication?

Yes

If yes, please list

Known safeguarding concerns?

Yes

Not aware

If yes, please provide details

5. Shared Care Confirmation

I confirm that this GP practice agrees to shared care for ongoing ADHD medication management following diagnosis, in accordance with NHS Right to Choose requirements.

6. Declaration