Thank you for taking the first step. This detailed form is a crucial part of the ADHD assessment process. Its purpose is to help us understand your unique experiences. Many people experience challenges with attention, organization, or restlessness. However, a clinical diagnosis of ADHD requires more than just the presence of these symptoms. A key component of the diagnosis is demonstrating that these symptoms have caused significant, long-term impairments in major areas of life (such as academic performance, career progression, relationships, or daily management) since childhood. As you complete this form, please think deeply about the real-world impact of your challenges. We are looking for clear, concrete examples of how these difficulties have consistently interfered with or reduced the quality of your functioning. This detailed information allows for a thorough and accurate assessment.

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.

A diagnosis of ADHD requires clear evidence that symptoms have significantly impaired your functioning in two or more areas of your life. On this ADHD Symptoms Page (click the link) you will find the symptoms as outlined by the Diagnostic and Statistical Manual. Please take some time to reflect on how these symptoms have directly impacted you in the domains below. Try to avoid vague statements like "I'm bad with deadlines" as these are less helpful than concrete examples like "I received a formal warning at work for submitting three major reports late, costing the company a client."

1. Academic Impairment (Primary School, High School, and/or University/College) * Please describe any persistent challenges you faced in your academic career.

Consider: • Underachieving despite high potential (e.g., "My teachers always said I was bright but lazy"). • Needing to spend far more time studying than peers for the same results. • Failing grades, repeating years, or dropping out. • Disciplinary issues (e.g., detention for talking, being disruptive, not handing in homework). • Comments on report cards that reflect inattention, disorganization or hyperactivity.

2. Occupational Impairment (Work Life) * Describe any significant and recurring challenges you've faced in your career. If you have not worked, please type N/A.

Consider: • Being fired, demoted, or placed on performance review due to issues with organization, deadlines, or mistakes. • Frequently changing jobs or an inability to sustain employment. • Under-employment (i.e., working in jobs significantly below your capabilities/qualifications). • Significant conflict with colleagues or managers stemming from your symptoms. • Missed promotions or opportunities due to inconsistent performance.

3. Social & Daily Life Impairment * Describe challenges in your personal life outside of work and school.

Consider: • Relationships: Difficulty maintaining long-term friendships or romantic partnerships; frequent arguments over things like forgetfulness, messiness, or not listening. • Daily Chores & Finances: A chronically disorganized/messy living space; significant trouble with paying bills on time (e.g., incurring late fees); impulsive spending leading to financial strain. • Driving: Multiple traffic violations, accidents, or near-misses due to inattention. • Parenting (if applicable): Significant challenges with maintaining routines, organization, and patience as a parent.

Please note that Dayne Williams & associates 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.

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

Bank Details

Account Holder: Dayne Williams and associates

Bank Name: First National Bank (FNB)

Branch Number: 050655

Account Number: 63117157156

Please use name and surname as a reference

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

1. Confidentiality and Privacy: I acknowledge that all private information shared in the therapeutic process will be treated as highly confidential. No information will be disclosed without my explicit consent unless required by a Court of Law. While every precaution is taken to ensure the security of electronic communications, I acknowledge that online platforms may pose inherent risks to privacy and confidentiality.

2. Informed Consent: I confirm that I am providing this consent willingly, without undue influence from any party.

3. Communication Platforms: I consent to the transmission of information and reports (where applicable) via email, Google Meet, and/or WhatsApp. I understand that these platforms will be used to share relevant information with me or other specified medical practitioners as necessary. I acknowledge that despite efforts to secure all digital platforms, electronic transmission of information can carry some privacy risks, including potential breaches beyond the practitioner’s control.

4. Data recording I consent to the audio recording of the clinical interview for diagnostic and analytical purposes. All recordings will be stored safely until the assessment process has concluded in which case they will be promptly deleted.

5. Invoices and Payments: I consent to the communication of invoices to the designated person indicated above and confirm that I am aware of the payment terms as outlined in the confirmation email. Should the practitioner need to submit claims directly to my medical aid, I grant permission for this process.