Questionnaire

Form

If you are interested in booking an appointment for an ADHD assessment, please complete the questionnaire and take the ADHD screening test. We will try and get back to you within a timely manner. Please note that due to our limited availability, we are not able to accommodate everyone. And if you are seeking a consultation for another reason, please complete the questionnaire and state the reason for which you are requesting a consult in the “additional comments” section/box below.

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Full Name*

First Last

Contact Email*

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Date of Birth*

Occupation*

Psychiatric or medical diagnoses*

Number of hospitalization(s)*

Reason for hospitalization(s)*

Past or current medications*

Allergies*

History of alcohol or drug abuse*

History of alcohol or drug rehab / treatment*

History of suicide attempts*

Additional info

If you are seeking a consultation for another reason, please complete the questionnaire and state the reason you are requesting a consult.

Reason for Consulation Request

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