Summary of Medical History
e.g. any previous diagnoses such as Attention Deficit Hyperactivity Disorder (ADHD), Autism, developmental co-ordination disorder (DCD), dyspraxia, learning disability, specific learning difficulty, mental health diagnoses etc.
Please share any medications that are currently being prescribed:
Any Prior / Current Professionals Involved
e.g. any previous/current involvement with mental health services, learning disabilities service etc.
Reason for request for support
e.g. identified areas of difficulty for which further assessment/treatment may be required:
Area/s you require assessment/advice Tick if relevant
Possible Autism
Possible attention deficit hyperactivity disorder (ADHD)
Please provide any further information/details regarding the above:
Consent of person being referred I consent to this referral being made to Provide Wellbeing
Name………………………………………………… Date…………………………………….
Signature….…………………………………………
I consent for my details to be stored by Provide Wellbeing in line with Data Protection Legislation
Name………………………………………………… Date…………………………………….
Signature….…………………………………………
I consent for my report and/or additional follow up letters to be shared with my registered GP Practice
Name…………………………………………………
Signature….…………………………………………
Please return completed form and questionnaires to: provide.wellbeing@nhs.net