• Adult Neurodevelopmental Home Assessment Form 1 

  • Welcome to your comprehensive online Neurodevelopmental self-assessment forms. We understand that form filling can be a daunting task, but rest assured, your input is vital for an accurate assessment. By sharing as much information as possible, you allow us to gain a clearer understanding of your unique experiences. Embrace this opportunity to provide valuable insights into your mental health, as it will greatly assist us in tailoring our support to your needs. Thank you for embarking on this essential step towards a better understanding of yourself.

    Please note - this form will ask you questions about your birth, delivery, and development as an infant, including questions about whether you were delayed in learning to walk/talk/etc. As such - you may want to speak to a parent before setting out to complete your form. 

    This form is quite extensive and may take you up to an hour. Please use the 'Save' button below and create a JotForm account with your email. This will prevent the loss of data and allow you to resume editing your form at a later point. Regularly save your progress to avoid losing data.

    Please make sure to contact our team if you have questions or require assistance:  enquiries@adhddirect.co.uk 

    • Click here to enter your contact details 
    • Date of birth*
       - -
      2 digit day, 2 digit month, 4 digit year
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    • PLEASE NOTE: occasionally our JotForm system may encounter errors. If you find yourself unable to upload all the necessary documents due to file size or type restrictions, we kindly request that you send these files to us manually as soon as possible. Please forward the required documents to our dedicated email address, enquiries@adhddirect.co.uk. Our team will promptly process your information and ensure that it is appropriately handled.

    • Regularly save your progress to avoid losing data.

      Please contact our team if you have questions or require assistance: | enquiries@adhddirect.co.uk

  • OBSERVER DETAILS:

  • As part of your neurodevelopmental assessment, we will also need to receive information about you from an 'observer' - that is someone who knows you well, such as a parent, close relative, or friend. 

    We need you to clarify who your observer is, how you know them, and what their contact details are. 

    Completing the below information presumes that you consent to us reaching out and contacting this person. We will then send them a number of observer forms to complete. These will include questions about you, the patient. 

    • Click here to provide your observer details.  
    • Format: 00000 000 000.

    • Regularly save your progress to avoid losing data.

      Please contact our team if you have questions or require assistance: | enquiries@adhddirect.co.uk 

    • Click here to tell us about any previous ADHD/Autism/Mental Health assessments that you may have undertaken.  
    • Browse Files
      Drag and drop files here
      Choose a file
      Cancelof

    • PLEASE NOTE: occasionally our JotForm system may encounter errors. If you find yourself unable to upload all the necessary documents due to file size or type restrictions, we kindly request that you send these files to us manually as soon as possible. Please forward the required documents to our dedicated email address, enquiries@adhddirect.co.uk. Our team will promptly process your information and ensure that it is appropriately handled.

    • Click here to tell us the main reasons you are looking to attend for an neurodevelopmental assessment 

    • Regularly save your progress to avoid losing data.

      Please contact our team if you have questions or require assistance: | enquiries@adhddirect.co.uk 

  • Family History

  • Please complete the following information about you and your family. 

    If any questions do not apply to you, simply write 'N/A' (Not Applicable) in the space provided, or else leave the space blank. 

    • Click here to answer questions about your family composition  
    • Do you have any children?*

  • Family Psychiatric History

    The checklists below should be used to describe any family history of psychiatric or learning problems.
    • Click here to provide details regarding your family psychiatric history. 
    • Issues with aggression or defiance.*
    • Issues with inattention*
    • Issues with hyperactivity and impulsivity*
    • Learning Problems*
    • Failed to graduate high school*
    • Experiences psychosis*
    • Has depression or a mood disorder*
    • Has anxiety or an anxiety disorder*
    • Has bipolar disorder*
    • Has a tic disorder*
    • Issues with alcohol or other substance abuse*

    • Regularly save your progress to avoid losing data.

      Please contact our team if you have questions or require assistance: | enquiries@adhddirect.co.uk 

  • Early years

    Tell us a bit about your early childhood and teen years.

  • Please tell us as much as you can about your early years. If there are things you don’t remember, you might wish to ask your parents (if appropriate) or siblings, as they may be able to help. If you are unable to provide certain information, please type or select “Don’t know.”

    • Pregnancy and Birth 
    • Were there any complications or concerns during your mother’s pregnancy?*
    • Did your mother use any of the following substances or medications during her pregnancy?*
    • Were there any concerns with your health following your birth?*

    • Regularly save your progress to avoid losing data.

      Please contact our team if you have questions or require assistance: | enquiries@adhddirect.co.uk |

  • Early temperament

    • Click here to tell us about your early temperament 
    • Were any of the following difficulties present during the first few years of your life?*
    • Click here to answer questions about your developmental milestones 

    • Developmental milestones

      These questions will help us understand whether your development in certain areas may have been different. You may not be able to answer all of them, and you might need to ask a family member for some details. Please just answer as much as you can.
    • *
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    • Regularly save your progress to avoid losing data.

      Please contact our team if you have questions or require assistance: | enquiries@adhddirect.co.uk | 

  • School years

    Tell us a bit about what your school experience was like: what you enjoyed, and what you found more difficult.
    • Click here to tell us about your educational history.  
    • Click here to tell us about any issues you may have had in primary school or high school. 
    • *
      Rows
    • Click here to tell us about your educational experience:  

    • Regularly save your progress to avoid losing data.

      Please contact our team if you have questions or require assistance: | enquiries@adhddirect.co.uk |

  • Wender Utah Rating Scale (WURS-25)

  • The Wender Utah Rating Scale (WURS) is a questionnaire that helps identify symptoms of childhood ADHD that may continue into adulthood. Please answer each question as accurately as you can, thinking back to how you were as a child. Your responses will support a fuller understanding of your developmental history and is helpful for both an ADHD or an ASD assessment.

  • As a child I was (or had): *
    Rows

  • Employment History

    • Click here to tell us about any current employment.  
    • Are you currently employed?*

    • Regularly save your progress to avoid losing data.

      Please contact our team if you have questions or require assistance: | enquiries@adhddirect.co.uk 

  • Further Questions

    We’d like you to complete a few questions to help us identify any other health conditions that might exist alongside your current difficulties. This information helps us understand whether any additional factors could influence your assessment and overall care.
  • Tell us about any tics you may have noticed:
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  • Tell us about your childhood development. Did you have any problems with:
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  • PHQ-9

    The PHQ-9 is a brief questionnaire used to assess your mood and identify symptoms of depression. Please answer each question based on how you’ve felt over the past two weeks. Your responses will help us better understand your current wellbeing and guide any support you may need.
  • 1) Little interest or pleasure in doing things*
  • 2. Feeling down, depressed, or hopeless*
  • 3. Trouble falling or staying asleep, or sleeping too much*
  • 4. Feeling tired or having little energy*
  • 5. Poor appetite or overeating*
  • 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down*
  • 7. Trouble concentrating on things, such as reading the newspaper or watching television*
  • 8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual*
  • 9. Thoughts that you would be better off dead or of hurting yourself in some way*

  • Do you currently find yourself doing the following?

  • Nail biting*
  • Skin picking*
  • Pulling out own hair*
  • Hoarding items*

  • GAD-7

    The GAD-7 is a short questionnaire designed to measure symptoms of anxiety. Please answer each question based on how you’ve felt over the past two weeks. Your responses will help us understand your current levels of anxiety and support you in accessing the most appropriate care.
  • 1. Feeling nervous, anxious, or on edge*
  • 2. Not being able to stop or control worrying*
  • 3. Worrying too much about different things*
  • 4. Trouble relaxing*
  • 5. Being so restless that it is hard to sit still*
  • 6. Becoming easily annoyed or irritable*
  • 7. Feeling afraid, as if something awful might happen*

  • Some people experience significant trauma in their lives:

  • Are you affected by any past trauma?*
  • If so, do you ever experience flashbacks and distress?*

  • Have you ever experienced the following?

  • *
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  • The use of alcohol, drugs, or other impulsive behaviours can be more common in people who are neurodivergent, often as a way of coping with stress, boredom, or emotional difficulties.

  • We ask about these areas to help us build a full and accurate picture of your background and wellbeing. Please be assured that any information you share is strictly confidential and used only to guide your care and assessment.

  • We’re keen to hear about your alcohol use, smoking history, and any recreational drug use (if applicable). Both past and present use are important to understand, as this information helps us gain a complete picture of your health and wellbeing.

    • Alcohol Use:  
    • How often do you have a drink containing alcohol?*
    • How many drinks containing alcohol do you have on a typical day when you are drinking?*
    • How often do you have six or more drinks on one occasion?*
    • How often during the last year have you found that you were not able to stop drinking once you had started?*
    • How often during the last year have you failed to do what was normally expected from you because of drinking?*
    • How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?*
    • How often during the last year have you had a feeling of guilt or remorse after drinking?*
    • How often during the last year have you been unable to remember what happened the night before because you had been drinking?*
    • Have you or someone else been injured as a result of your drinking?*
    • Has a relative, friend, doctor, or other health worker been concerned about your drinking or suggested you cut down?*
    • Drug Use:  
    • 1.Have you used drugs other than those required for medical reasons?*
    • 2. Do you abuse more than one drug at a time?*
    • 3. Are you always able to stop using drugs when you want to? (If you never use drugs, answer “Yes.”*
    • 4.Have you had "blackouts" or "flashbacks" as a result of drug use?*
    • 5. Do you ever feel bad or guilty about your drug use? If you never use drugs, choose “No.”*
    • 6.Does your spouse (or parents) ever complain about your involvement with drugs?*
    • 7.Have you neglected your family because of your use of drugs?*
    • 8.Have you engaged in illegal activities in order to obtain drugs?*
    • 9.Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?*
    • 10.Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)?*
    • Caffeine Intake:  
    • Do you consume caffeine or high‑caffeine energy drinks? (more than 5 drinks a day)*

  • Tell us about your relationship with food. Have you experienced any of the following?

  • *
    Rows

  • The Adult Autism Spectrum Quotient (AQ-10)

  • The AQ-10 (Autism-Spectrum Quotient-10) is a brief screening questionnaire used to identify traits associated with Autism Spectrum Disorder (ASD) in adults.

    It includes ten questions about social understanding, communication, and attention to detail. We use the AQ-10 as part of both our ADHD and ASD assessments, as there is often a significant overlap in traits between the two conditions.

    The results provide helpful insight into your neurodevelopmental profile and guide us in determining whether further autism-focused assessment or support may be appropriate.

  • Below are a list of statements. Please read each statement very carefully and rate how strongly you agree or disagree. Please do not miss any statement out. *
    Rows

  • Strengths

    We realise that we have focussed largely on problems and difficulties that you may be having. However, we are also interested to understand your strengths, talents, skills, and accomplishments.

  • Regularly save your progress to avoid losing data.

    Please contact our team if you have questions or require assistance: | enquiries@adhddirect.co.uk | 

  • Medical History Checklist

  • Please clarify if you have history of any of the following conditions:*
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  • Important Information - Measurements

  • As part of the ADHD and/or ASD assessment process, we ask for some basic health measurements.

    This helps us gain a general understanding of your overall health and wellbeing, including your cardiovascular status (for example, your blood pressure, heart rate, and weight).

    If a diagnosis of ADHD, ASD, or both is confirmed, and medication is being considered as part of your treatment plan, we will need these measurements in order to proceed safely.

    Please try to have these measurements completed before submitting this form or bring them with you to your appointment. This will help us ensure your care is managed efficiently and safely.

  • *
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  • For ADHD Direct patients who need to record their height, weight, and blood pressure, there are a few convenient options available:

    1. Measure at home:
    You may wish to purchase your own equipment online at an affordable price. A digital scale can provide accurate weight readings, and a home blood pressure monitor allows you to track your blood pressure easily and reliably.

    2. Visit a healthcare professional:
    Alternatively, you can have these measurements taken at your GP practice, by a practice nurse, or at an NHS pharmacy. They have the appropriate equipment and expertise to take accurate measurements and can provide guidance to ensure reliable results.

  • Significant Medical Conditions

  • Please clarify if there is any history (past or current) of the following conditions:*
    Rows

  • Medication History

  • Please give the details of your full medication history. If you have not been on any significant medications, please type N/A in each of the three boxes below. *

  • Regularly save your progress to avoid losing data.

    Please contact our team if you have questions or require assistance: | enquiries@adhddirect.co.uk | 

  • Shadowing Consent:

  • At ADHD Direct, we have an ongoing programme of training and supervision for clinicians who wish to specialise in the field of neurodiversity. As part of this, we frequently work with clinicians who are developing their clinical skills.

    In order to gain experience, these clinicians must be supervised or shadowed by a more senior clinician. This means that, in some appointments, there may be two clinicians present—one conducting the assessment and the other observing or assisting under supervision.

    All clinicians, including those in training, are strictly bound by confidentiality rules. You have the right to choose whether you are comfortable with having an additional clinician in the room during your appointment. You can also decide whether you are happy for them to take an active role in your assessment.

    Whatever you decide, we fully respect your wishes, and your choice will never affect the quality of your care or treatment.

  • Do you consent to having a student or clinician shadow your appointment? (This means they will be present in the room, observing your assessment.)*
  • Do you consent to your shadowing a student or clinician participating in your assessment?*

  • Consent to Contact Your GP

  • In order to provide a thorough neurodevelopmental assessment and safe, effective treatment, we request your consent to communicate with your General Practitioner (GP). This may include obtaining a GP summary sheet and, where necessary, additional information about your medical history.

    Following your appointment, we will also share relevant information with your GP typically in the form of a written assessment letter outlining the outcome of your assessment.

    This collaboration is clinically essential to ensure an integrated and informed approach to your care. Engaging with your GP allows for a more complete understanding of your health, supports coordination between healthcare providers, and helps us deliver the safest and most effective treatment plan.

    Please note: we do require this consent in order to proceed with your neurodevelopmental assessment.

  • If you do not consent to ADHD Direct communicating and sharing information with your GP then please get in touch with our admin team as soon as possible to explain why you are unable to provide this consent and we can discuss this matter with you directly: enquiries@adhddirect.co.uk 

  • Transcript Consent

    Heidi AI is a secure speech-to-text tool used during ADHD assessments. It helps your clinician capture important details accurately so we can populate your clinical report. Are you happy for your clinician to use Heidi AI or a similar voice to text transcription tool to transcribe your consultation? It does not keep an audio recording of your voice; it simply converts what is said into written text, which our typists then use to check and complete your report accurately.
  • Do you consent to ADHD Direct using Heidi AI during your assessment?*

  • Thank you!

  • We want to extend a big thank you for taking the time and effort to complete these important forms. We know it's not always easy, but your input is incredibly valuable to us.

     

    Now that you've filled out the forms, simply hit the "Submit" button to take the next step. We appreciate your cooperation and trust in our assessment process.

     

    Additionally, please note that we will be using the observer details you provided to send out forms to your named observer. You may want to give them a nudge and ask them to look out for these forms. Thank you for including this information and helping us gather a comprehensive understanding of your situation.

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