Adult ADHD assessment intake and consent form

Intake and consent form - ADHD assessment - Cathryne Baird

Please fill out the following form to assist the assessment process. NB: All information submitted via this form is strictly confidential and stored securely. Please read our privacy policy for more information about how your information is used and stored at www.daynewilliams.co.za/privacypolicy

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Medical aid details

Should you not have medical aid or choose to not use it then you can simply type NA (Not applicable) in the medical aid info boxes below.

Principal member name:

First

Last

Medical aid scheme:

Membership number:

Dependent code: (necessary if the patient is not the main medical aid member)

Benefit option: (eg. coastal saver)

Referring doctor (if applicable)

Details of person responsible for account

Please note that a copy of the confirmation will be sent to the person responsible for payment

Name

First

Last

Contact number:

Details of patient:

Name of patient:

First

Last

Date of birth:

Contact number:

Medical History (Please complete this as accurately as possible)

Please detail any history (if applicable) of ADHD in your immediate family (parents/siblings etc)

Please indicate your birth weight

Please indicate whether your mother consumed alcohol or nicotine during preganacy

Please elaborate (if any) on language related learning barriers experienced during primary/high school

Have social skills and interpersonal relationships been a challenge for you? This can be elaborated on during the assessment.

Very often (very frequently)
Often (or quite a bit)
Occasionally
Never (or seldom happened)

Please indicate if you have been treated for any of the following:

Please indicate if you have experienced any traumatic brain injuries during your lifetime

At what age did you first experience symptoms?

What has led to you choosing the present moment to assess for possible ADHD?

Please provide the name and email address of a person with whom you currently live that I can contact regarding your assessment. Should you currently live alone, please provide the name and email address of a family member with whom you have lived in the past. Please note this is an important step and must be someone who can speak to the symptoms you have shown. ADHD must be present in two or more settings and therefore this element of the assessment is crucial.

Name

First

Last

During the assessment you will be asked to provide clear evidence (concrete examples) of how the symptoms, indicative of ADHD, have "interfered with, or reduced the quality of, social, academic, or occupational functioning". On this ADHD Symptoms Page (click the link) you will find the symptoms as outlined by the Diagnostic and Statistical Manual.

Please take a moment to summarize some key talking points regarding impairment that you can elaborate on in the assessment. Remember these must be clear, concrete examples. Lastly, please do not use any other symptoms apart from those listed in the link above.

(optional) Please feel free to share any additional information you feel is relevant to your assessment (copy)

Payment instructions

Please note that Dayne williams & Assosiates operates as a cash practice and therefore the patient is responsible for payment. Once payment has been made you will be issued with a receipt which can be used to claim back from medical aid. Please consult your medical aid first to ensure funds are available for psychological sessions. Once this intake form is received an invoice will be issued to you with the banking details for EFT.

Payment must be made on or before the day of assessment with a POP sent to accounts@daynewilliams.co.za. No assessments can commence without this. Please find banking details below

Banking Details

Account Holder: D Williams & Associates

Bank Name: FNB

Branch Number: 050655

Account Number: 63117157156

Please use name and surname as a reference

Consent form

I hereby give permission for Cathryne Baird to interview, assess and provide treatment in accordance with the guidelines and terms mentioned below:

2. Acknowledge that all private information collected about you will be treated as highly confidential; no information will be disclosed without your consent, unless required to do so by the Court of Law.

3. Acknowledge that I/we gave my/our consent, willingly and without being unduly influenced to do so by any person.

4. Give consent to communicate information and reports (where applicable) via email and/or Whatsapp messaging platform to you and/or other medical practitioners.

5. Acknowledge that invoices will be communicated to the person indicated above and that the payment conditions (as outlined in the confirmation email) have been noted. Should the practitioner need to submit direct to medical aid for whatever reason, then this is accepted by the patient.

Signature of patient

Clear Signature

Please use mouse (pc) or finger (phone/tablet) to sign above

Date