ADHD Pre-Referral Form for Under 18s

ADHD Pre-Referral Form for Under 18s

About the child

Child's Name
DD slash MM slash YYYY
Address
Not at allJust a littleQuite a bitVery much
Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
Often has difficulty sustaining attention in tasks or play activities
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish schoolwork, chores or duties
Often has difficulty organising tasks and activities
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework)
Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books or tools)
Often is distracted by extraneous stimuli
Often is forgetful in daily activities
Often fidgets with hands or feet or squirms in seat
Often leaves seat in classroom or in other situations in which remaining seated is expected
Often runs about or climbs excessively in situations in which it is inappropriate
Often has difficulty playing or engaging in leisure activities quietly
Often is “on the go” or often acts as if “driven by a motor”
Often talks excessively
Often blurts out answers before questions have been completed
Often has difficulty awaiting turn
Often interrupts or intrudes on others (e.g., butts into conversations/games)
Often loses temper
Often argues with adults
Often actively defies or refuses adult requests or rules
Often deliberately does things that annoy other people
Often blames others for his or her mistakes or misbehaviour
Often is touchy or easily annoyed by others
Often is angry and resentful
Often is spiteful or vindictive