Application for Online Access

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All questions marked with a * are mandatory

Personal Details
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Pre Assessment
A few sentences summarising any symptoms you are experiencing that could impact your daily living, social life, and/or work life, and that may have been evident since childhood.
Consider what you would like to gain from an assessment and any potential ongoing treatment.
Are you currently taking ADHD medication?: *
Choice of Provider
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Clinical screening questions
Have you ever been diagnosed with any of the following mental health conditions?: *
Have you ever experienced any of the following?: *
Have you ever been admitted to hospital due to your mental health?: *
Are you currently under the care of a mental health service, or have you been within the last 12 months?: *
Do any of the following apply to you?: *
For example, interpreter requirements, hearing or visual impairment, or any reasonable adjustments required
Do you consent to a family member or representative being involved in communication regarding your assessment?: *
Are you currently taking any medication?: *
Do you have any known allergies?: *
Harrow Health cardiac screening
Do you experience any of the following cardiac symptoms or have a relevant cardiac history?: *
Physical Health Observations
Your chosen provider requires a recent blood pressure, pulse and weight/height reading. Have you had these measurements taken recently?: *
Ideally within the last 3 to 6 months. However, if older readings are available, patients may still provide them. If not available, these can be arranged by the GP surgery later.
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Upload all completed documents

Psychiatry UK

Please ensure you have completed:

  • Questionnaire
  • Right to Choose letter addressed to Dr Mehta

Visit the Psychiatry UK website

ADHD 360

Please ensure you have completed:

  • Cover letter
  • Referral form
  • Risk assessment

Visit the ADHD 360 website

Is your previous diagnosis report available?:

Atrom Mindcare

Please ensure you have completed:

  • Online questionnaire (download the results)

Visit the Atrom Mindcare website

Problem Shared

Please ensure you have completed:

  • Questionnaires

Visit the Problem Shared website

Harrow Health

Please ensure you have completed:

  • A signed Right to Choose letter available on their website.

Visit the Harrow Health website

Care ADHD

Please ensure you have completed:

  • ADHD questionnaire

Visit the Care ADHD website

Harley Street Mental Health

Please ensure you have completed:

  • Questionnaire
  • Right to Choose letter addressed to Dr Mehta

Visit the Harley Street Mental Health website

Clinical Partners

Please ensure you have completed:

  • Questionnaire

Visit the Clinical Partners website

Health Harmonie Minds

Please ensure you have completed:

  • No mandatory forms are required from the patient for this service.

Visit the Health Harmonie Minds website

Dr J & Colleagues

Please ensure you have completed:

  • All required patient forms listed on their website

Visit the Dr J & Colleagues website

RTN Mental Health Solutions

Please ensure you have completed:

  • Self-report
  • GP letter addressed to Dr Mehta

Visit the RTN Mental Health Solutions website

Innovate ADHD

Please ensure you have completed:

  • Right to Choose referral form

Visit the Innovate ADHD website

Skylight Psychiatry

Please ensure you have completed:

  • Questionnaire
  • Right to Choose letter addressed to Dr Mehta

Visit the Skylight Psychiatry website

Psicon

Please ensure you have completed:

  • No mandatory forms are required from the patient for this service.
  • If you would like to complete the ASRS questionnaire, please upload in the upload section before submitting this form.

Visit the Psicon website

Sinclair-Strong Consultants

Please ensure you have completed:

  • All required patient forms

Visit the Sinclair-Strong Consultants website

‘Other’ provider: 

  • If any provider patients forms or questionnaires are required, please upload all completed documents in the upload section before submitting this form.

Incomplete submissions may delay referral

Please upload all completed documents below

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Please upload documents in PDF or image format where possible. If you are unable to upload documents, please email them to cahccg.richmondroadsurgery@nhs.net

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Confirmation and consent

Please review and confirm the following before submitting your referral request.

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