Adult ADHD NHS Referral

Name: Chelmsford Health Centre
Address: Dickens Place, Chelmsford, Essex, CM1 4UU, GB
Telephone: 01245 690 680
Price range: ££
Rating: 4.8

NHS Right to Choose · Chelmsford Health Centre

For use by referring GPs and clinicians only. All fields marked * are required.

Prefer to submit a paper form?

Download, complete and email to referrals@chelmsfordhealthcentre.com

Download Referral Form

1. Patient Details

Full Name *

Date of Birth (DD/MM/YYYY) *

Address (first line & postcode)

Town / City *

NHS Number (if available)

Contact Telephone

Email Address

2. Referring GP / Clinician

Clinician Name *

Practice Name *

Practice Email *

Practice Telephone

3. Clinical Information

Key Presenting Concerns (tick all that apply)

InattentionHyperactivityImpulsivityEmotional dysregulationOther

Reason for referral / relevant history (optional — full history taken at assessment)

4. Safety & Medication

Current psychiatric medication?

YesNo

Known safeguarding concerns?

YesNoNot aware

5. Shared Care Confirmation

I confirm that this GP practice agrees to shared care for ongoing ADHD medication management following diagnosis, in accordance with NHS Right to Choose requirements. *

6. Declaration

By submitting this form I confirm that I have the patient's consent to share their information with Chelmsford Health Centre for the purpose of this referral, and that the information provided is accurate to the best of my knowledge.

Submitted securely to referrals@chelmsfordhealthcentre.com · 01245 690 680