Consent Form, Intake and PreCore - The Adult Autism and ADHD Practice

The Adult Autism and ADHD Practice Intake Form
Hi, my name is Davida Hartman, I am the Clinical Director of The Adult Autism Practice, and late identified ADHD.

Our team considers it a great priviledge that you have chosen us to support you in your identification journey.

If you haven't already, I would recommend reading through the Frequently Asked Questions section of our website.

It is very important to us that you feel prepared and comfortable, every step of the way. So, if you are unsure about anything or do not agree with anything in this form, please email us at info@adultautism.ie and we will do our utmost to help.

If you are ready to start, this form has 4 different main sections.

1. A Consent Form

2. An Autistic Experience Intake Form (which you only need to fill in if you are going to be undertaking additional in depth invesitgation of Autism)

3. An ADHD Experience Intake Form (which you only need to fill in if you are going to be undertaking additional in depth invesitgation of ADHD)

4. CORE-OM Form

The Consent Form introduces who we are and how we work, and gathers some basic details about you and allows you to give your consent to proceed further.

The Autistic Experience Intake Form allows you to share more detailed experiences about your life, in the many areas related to the Autistic experience.

The ADHD Experience Intake Form allows you to share more detailed experiences in the areas related to the ADHD experience.

The CORE-OM Form is a questionnaire about your current mental health.

Completing everything in this form is likely to take a long time. You will be able to save it as you go along.

Please ensure to click SUBMIT at the very end of this form or we will not receive it.

Please note that incomplete submissions will be automatically deleted after 60 days.

Here are the steps of the process of booking in and working with us:

1. Read the FAQ on our website

2. When you are ready, click the ‘Make a Booking’ button

3. Fill in the Intake Form and submit. You will be given the opportunity there to choose what option you would like. If you are only doing Autistic identification with us, you do not need to fill in the ADHD intake questions and if you are only doing ADHD identification, you do not need to fill in the Autistic expierience questions

4. You are now on our waiting list. We will send you an invite email as soon as you reach the top (keep an eye on your junkmail folder!)

5. Respond to the invite email saying that you are ready to pay and book

6. Wait to receive an invoice and then make payment online. Let us know you have paid

7. View online psychologists’ calendars

8. If you are booking for a Consultation, book 1 appointment. If you are booking for an Autistic or ADHD identification only, book 3 appointments. If you are attending for Autistic & ADHD identification, book 5. However, please note that psychologists may only have 1-2 sessions available. In that case it is ok, just book in as many as you can and you can discuss with your psychologist about dates/times for future appointments. If you are booking in for Autistic & ADHD identification, make sure to book in with a psychologist who supports both (this will be clear in the psychologist’s information)

9. If you attend for a Consultation, and want to continue with a full identification (of a choice of just Autistic, just ADHD or Autistic & ADHD) contact us to let us know. You will then be sent another invoice to pay. Once this is paid, you can book in for further sessions (2 more sessions if just Autistic OR ADHD, 4 sessions if looking at both)

10. If you are identified as Autistic and/or ADHD, allow 2 weeks for documentation. You can also book your appointment with Thriving Autistic (this can be at any time)

11. If you are not identified as either, you can still attend a complimentary follow up session with Thriving Autistic. You can also receive a document confirming the outcome if you want one

We very much look forward to getting to know you!

Warmly,

Davida

What do you want to attend for?

Please choose one of the below options. For more information on Consultations and Assessments (including prices), see our website. There is no difference in wait-time between any of these options. If you want to explore Autistic experience alone, and decide later if you want to explore ADHD, that is also ok, you can just click on Autistic experience only.
Pick one option only*

Consultation - Autistic experience onlyConsultation - Autistic & ADHD experienceConsultation - ADHD experience onlyAssessment - Autistic experience onlyAssessment - ADHD experience onlyAssessment - Autistic & ADHD experienceFollow on ADHD Assessment (only available for clients who have previously attended The Adult Autism Practice)

Email*
example@example.com
IMPORTANT NOTE: The Adult Autism & ADHD Practice is not an adult mental health service. Our focus is solely on adult, autism identification (alongside ADHD identification). If you are experiencing significant mental health issues (e.g., suicidal thoughts or self-harming), for your own safety and well-being it is vital you seek support from the right services/professionals, before attending with us.

If UK based, you can contact:
1. Your GP, who can help you access a referral for psychological talking therapy in your area.
2. Samaritans freephone 116-123
3. Via TEXT www.crisistextline.uk 24/7 text servive
4. Text SHOUT to 85258 www.giveusashout.org
If based in Ireland, you can contact:
1. Your GP (or out of hours GP)
2. Samaritans freephone 116-123
3. TEXT Crisis Textline Ireland: 50808 is a free 24/7 text service. Text 3TS to 50808
4. The Psychological Society of Ireland
5. The Irish Association for Counselling and Psychotherapy
If you feel actively unable to keep yourself or others safe, please attend your nearest A&E department, where urgent mental health support is available.

Confidentiality

All sessions are confidential with The Adult Autism Practice, and this is very important to us. We will always respect your right to confidentiality.

However, there are certain limits to confidentiality. In circumstances where concerns arise regarding your safety and well-being or that of another adult or child, confidentiality cannot be guaranteed. This includes information provided in your submitted forms and/or emails, as well as information provided during sessions with your psychologist.

This means for example that should you give us information which indicates that a child may be at risk, this is something that we are ethically mandated to follow up and possibly report.

In the event where we feel we must break confidence, we will endeavor where possible and appropriate to discuss this with you beforehand.

For clients in Ireland, psychologists are legally obliged to report all situations of potential risk or harm to those under 18.

Note: Online sessions will not be recorded in any format by us, and it is not permitted for sessions to be recorded by you.
Limitations to Confidentiality

Please be aware that there are some occasions when if past abuse/risk is reported to us we are legally obliged to report it to the relevant authority/agency, for example if there is the ongoing risk to others. We would seek to discuss this with you first. If you have concerns about the limits of confidentiality then please do discuss with your psychologist.

Where You Live is Important

We mostly see clients from the UK, Ireland and wider Europe.

However, we do see people living in other countries. If you currently live in a country that is not in the UK, Ireland or Europe, please email us at info@adultautism.ie, to see if your country can be covered.

If you live outside the UK or Ireland and hope to use your formal Autistic identification to access disability supports or other assistance, please check local legislation regarding the acceptance of a diagnosis from outside your country of residence.

Unfortunately, we cannot see clients residing in the USA or Canada, as regulations in these countries require your psychologist be registered in the specific US state or Canadian province in which you live.

If you are living in an eligible country that is not the UK or Ireland and are hoping to use your documentation for example to access disability supports, please make sure to check the requirements for accepting a diagnosis in the country you are living in. While we may be able to see and assess you, different countries have different rules around assessments and reports.

Location of Online Sessions

The platform we use for online sessions is Microsoft Teams. You might like to download and install Microsoft Teams (free of charge) prior to your session to become familiar with it, alternatively, if you are using a computer, you can also open the link in your browser without downloading Microsoft Teams.

You can book sessions directly with your psychologist and they will email you the Teams meeting details.

Confidentiality of Online Space

Due to the nature of working online, we cannot control all aspects of confidentiality as we can in face to face therapy sessions in a physical space. We have chosen to conduct online sessions through Microsoft Teams because they adhere to the HIPAA and EU GDPR standards for data protection.

Linking in with Other Services

It is important for you to let us know if you are currently linked with NHS or HSE adult mental health service (or similar).

The form provides a space for you to enter contact details for your service we will request your consent at this end of this form to contact the service and request information and/or collaboration.

For a Consultation, we generally do not contact these services. However, we still ask you provide their details and consent to contact.

We understand you may have had negative experiences of services in the past, been misunderstood or dismissed. Please be assured, you are at the centre of everything we do and we recognise you as the expert in your own experience.

Looking After Yourself

Consultations and assessments with us are usually a positive experience. The majority of the feedback we have gained from previous clients is that they found the process hopeful, supportive and much easier and less stressful than anticipated.

However, going on a personal journey of discovery such as this can surface difficult feelings, be tiring and overwhelming.

Because everything is online and we will not be physically present, it is important to have a plan for what to do in case you become distressed following a session. Please make sure to have a plan with a list of options to follow, if you do become distressed, e.g., phoning family members, friends or helplines. If you become concerned about your own safety and can’t access the support you need, you should attend an A&E department.

It would be a good idea to schedule relaxing activities on the days you have assessment sessions, particularly after sessions.

If you feel that the experience is going to be particularly overwhelming, you could also consider accessing some therapeutic support outside of The Adult Autism Practice either before, during or after the assessment.

If you experience significant distress during the period of the assessment, or just after it, please do let us know so that we can link you in with the right support.

Please note, we may recommend pausing your assessment journey, until you access some therapeutic support.

You will be asked later to provde the name and contact details of someone we can contact in an emergency. We will only contact this person if we are concerned for your safety and we are not able to get in contact with you.

Post Assessment Support Session

It is very important to us that the people we work with are well supported following what for many is a life transforming experience.

While we are an assessment (collaborative identification) and not a support service, we have been proactive in ensuring there is a solid support pathway in place for our clients.

Tara O’Donnell-Killen is our Support Lead at The Adult Autism Practice. She is an Autistic integrative professional with an MSc in Applied Positive & Coaching Psychology, extensive training in several psychotherapeutic modalities (CBT, ACT, Solution focused brief therapy, IFS/Parts therapy, Compassion focused and mindfulness based approaches) along with over two decades experience living and working in the US, Europe, Egypt, UK and Ireland supporting diverse groups of adults.

Tara founded Thriving Autistic in 2020, at the same time we started The Adult Autism Practice. Thriving Autistic is a team of professional coaches, psychologists, therapists and occupational therapists who are all themselves autistic or otherwise neurodivergent. The team at Thriving Autistic follow the same neurodiversity affirmative commitment to practice as our team. They are also highly skilled and experienced in the area of ADHD and neurodivergence in general.

As part of our assessment/collaborative identification package at The Adult Autism Practice, we offer one post assessment/identification support session with one of Tara's team at Thriving Autistic.

The follow up support session is designed to offer a supportive space for you to explore your feelings about the process and outcome of your sessions with us, to provide you with signposting to connect you to resources you may need and assist you with any immediate areas of concern.

The process is as follows:

If you are identified as Autistic and/or ADHD, your psychologist (with your consent) will email Thriving Autistic with a brief outline about your strengths and what you hope to focus on in the session. Thriving Autistic will then contact you by email to arrange your session.

Documentation

If you are identified as Autistic (and/or ADHD) during an assessment, you will be provided with strengths based, Neuro-Affirmative documentation that confirms your identification and which helps you understand how you met the criteria. We will also provide you with documentation to help with reasonable accomodations in work or college if you need it. This documentation will be emailed to you in PDF format.

Our "diagnosis" letters are accepted in health and education institutions in both Ireland and the UK. As stated previously, if living in a different country you will need to check their requirements.

There is an additional fee if you intend on applying for PIP (in the UK) or Disability Allowance (in Ireland). See our website for info on fees. Please let us know in advance as there are specific report requirements to access these that we can help you with if needed. A robust letter of this kind means that we spend additional time gathering relevant information from the material that you share with us. We need to go into detail doing this to make sure we provide evidence, where appropriate, to support you being awarded points. In order that we can provide you with a detailed letter we need to charge a higher amount to cover the additional staff costs and admin time of producing this detailed letter

Please note that if you opt for a single consultation rather than a full assessment, there will be no written documentation provided.

Also, please note that if you require additional documentation/letters outside of what we typically provide there will be an additional fee. In addition, if you require documentation in the future after some time as passed (i.e. several months) there will be an additional fee for all of this documentation.

We do not provide documentation for court purposes or legal proceedings. We also do not see clients actively engaging in most legal proceedings. Contact us by email if you have any particular circumstances you need to check with us about.

Cancellation Fee

Due to high demand for our services, a cancellation fee for individual sessions will be applied if less than 48 hours notice is given. If you cancel within 48 hours of your appointment or fail to attend without notifying the psychologist, a fee of €100/£84 will be charged.

Professional Records

It is a requirement to keep appropriate records of the services provided. Your records are maintained by our staff on a secure Microsoft server, secured by use of a password and a firewall with a secure access log and are accessible only to The Adult Autism Practice team. Any paper forms (e.g., if you choose to send a questionnaire in the post) are secured in locked filing cabinets in line with the Psychological Society of Ireland (PSI) ethical guidelines. All personal information is treated with respect and privacy to be read only as needed, in accordance with GDPR and the Psychological Society of Ireland guidelines.

Your session will not be audio or video recorded. Any notes we take during or after our session will be held securely in accordance with GDPR guidelines, we utilize a Microsoft suite of services as they are fully GDPR and HIPPA compliant.

You may always request to see what information is held about you at any given time – allowing notice to gather and share as per GDPR guidance.

Please note that by agreeing to be emailed copies of any documentation being transmitted to you, you are acknowledging there is a small risk of information being accessed by a third party during this transmission.

Consultation or Assessment*
Our Psychologists

We have a wonderful mix of psychologists from both the UK and Ireland on our team, who see a mix of clients from both regions (and abroad).

All UK based psychologists are registered with the HCPC (The Health and Care Professional's Council) (this is a requirement in the UK).

If you are based in the UK and see one of our Irish based psychologists, please be aware that they are not registered with the HCPC. This means that in the unlikely event of you having a concern you would need to raise it within the Irish system (e.g. the Psychological Society of Ireland) and not the HCPC.

The majority of Irish psychologists are members of the Psychological Society of Ireland (this is not a requirement in Ireland to practice as a psychologist). If you are currently based in Ireland and see one of our UK based psychologists, similarly you would need to raise concerns within the HCPC.

In no other way are the services provided by our psychologists any different.

When you are sent the selection of psychologists to choose from that have availabiliy, you may be able to choose between a UK or Irish based psychologist. However, please be aware that we cannot guarantee availability with a psychologist from a particular region.

We have a mix of Counselling, Clinical, Neuro and Educational Psychologists on our team. All psychologists are fully qualified for the work they are doing and working within their competencies. For example, our Educational Psychologists often see clients coming to us for Autistic experience assessments who are young adults. All reports from all of our psychologists will be accepted by all major organisations (e.g. NHS and colleges) as they comply with best practice guidelines.

The only thing to keep in mind here is if you are attending for ADHD identification, while the documentation is valid, if you wish to access medication this will not be possible from any assessment from a psychologist.

Any queries or requests in this area please email us.

Payment Plan (only tick if this applies to you, otherwise leave blank)

I want to avail of the payment plan.

Your Information
Name*

FirstLast
The name you would like us to call you
Preferred pronouns
Address*

Line 1

Line 2

Town/CityCounty

Postcode/Eircode
Email *
example@example.com
Phone*
Date of birth*

DayMonthYear
Age

I confirm that I am 18 or over.
General Practitioner's Details
Name*

FirstLast
Phone*
Address*

Line 1

Line 2

Town/CityCounty

Postcode/Eircode

Emergency Contact Information

We will only contact this person, if concerned for your well-being and unable to contact you by other means
Name*

FirstLast
Relationship to you*
E.g. mother, partner, brother
Email*
example@example.com
Phone*

Private Health Insurance

If you are based in Ireland and intend on claiming private health insurance, you will need to choose an Irish based Chartered Psychologist. Otherwise, please check with your individual private health insurance the specifics of your cover.
Do you intend on claiming insurance?

YesNo

Consent to Contact Adult Mental Health

This only applies if you are currently accessing adult mental health services from the NHS or HSE. It does not apply to private therapists.
I agree to give consent to The Adult Autism Practice to contact the key person from my adult mental health team. I have provided details for to communicate that I am to undertake an autism assessment and to request information/collaboration. I understand that this will only occur if I go ahead with a full assessment.

Yes I agreeNo I do not agreeNot Applicable

Adult Mental Health (AMH) Information

If you ticked the box in the previous page and are currently attending a public adult mental health team (e.g. with the NHS or HSE), please provide contact details here. If you are accessing therapeutic support privately you do not need to add their details here, although it would be helpful to include information about them in your Intake Forms (which will be sent to you at a later stage).
AMH Key Person's Name

First NameLast Name
AMH Key Person's Title
AMH Key Person's Contact Number
AMH Key Person's Address

Line 1

Line 2

CityCounty

Postcode/Eircode

Consent
Please read the following statements and tick if you give consent.*

I have read this informed consent online form and agree to its terms.If I am identified as Autistic, I consent to information from my assessment being shared with Tara O’Donnell-Killen, Support Lead and my practitioner at Thriving Autistic for the sole purpose of getting the most benefit out of the post-identification support session.I give consent for relevant information to be shared back to The Adult Autism Practice from Tara or a Thriving Autistic colleague, again for the sole purpose of best supporting my needs.I give consent for a Consultation and/or Assessment (Collaborative Autistic Identification) to be carried out to clinical autism assessment standards and in accordance with the professional and ethical guidelines of the Psychological Society of Ireland (PSI) or the Health and Care Professions Council (HCPC).I understand that The Adult Autism Practice is responsible for maintaining all professional standards set forth in the ethical principles of their professional associations, as well as legislation.I understand that all information shared with The Adult Autism Practice is confidential and no information will be released without my consent. However, I understand there are specific and limited exceptions to confidentiality and these are outlined in the section relating to confidentiality.I understand I can withdraw this consent at any time by writing to The Adult Autism Practice.

Additional information relating to anything you have read so far

2000 word limit0/2000

Signature

Clear
Date signed*

DayMonthYear
Parent Signature

Parent signature is required if this application is for a child who is 17 now but wishes to go on our waitlist in the understanding that they will not be seen by us until that are 18 years old.

Note: When the child turns 18 years old they will need to sign another consent before being seen.
Parent Signature

Clear

Autistic Experience Intake Form

The Adult Autism Practice
The purpose of this Intake Form is to gather information about you and how you experience the world. Your psychologist will use this information to help explore with you the question, 'Am I Autistic?'

However, we know that filling in forms like these can be overwhelming.

If, for any reason, you would prefer to talk these things through instead of filling in this form that is absolutely OK.

All you need to do in that instance is complete your name, email address and whether you are seeing a mental health professional (these are the 3 required sections in this form). You can then procced to the CORE and then click 'Submit' at the end of the form and proceed to your Consultation or Assessment as normal.

Why filling in this form is helpful
- Many of our clients have expressed that they feel anxious that they won’t be able to get out everything that they want to verbally during their video sessions. Sending this information to your psychologist in writing means that you can give all the information you want to give, in the way you want to give it.
- There is a lot of information that we need to cover. Providing this in advance means your session(s) will feel less rushed, as you'll have already covered lots of important areas.
- Sending the information to us in advance helps your psychologist know what the important areas are to focus on during your video session/s. After reading through this form, they will give you a plan in advance of each session of the areas you will be talking about.
- Anything you provide informs your psychologist of important areas to focus on during session(s). Reading your story, is a way of working together to make the most of your meetings.
Some important points about filling in this form
- You do not need to fill this form in all at once. If you click the 'Save' button at the end of the form you will be emailed a link to your form with the bits you have completed included.
- Your psychologist will read this form once you have booked into their diary. This form may also be read by our Assistant Psychologists or a member of our Client Support Team, as part of the process of ensuring you receive the right support throughout your journey.
- There's no 'ideal' amount of information to include. And within the word limit of 2000, you can go into as much or as little detail as you would like. However, if you do need to write more, you can certainly follow up with an email.
- Please don’t worry about spelling or grammar.
- Full sentences are not essential. Use bullet points or single words/phrases, if easier.
- Some of the areas you will complete are related to Autistic experiences, others are not. Everything is there to help your psychologist get to know you and your history better.
- If you come to a question that you have already answered in a previous section, you don’t need to write it out again.
- As mentioned previously, there's no need to complete any section you don’t want to. You can add something like, 'I’d prefer to talk about this in person' or, 'I feel uncomfortable sharing this information.' You can even leave it blank.
Your name*

FirstLast
Email*
example@example.com
Are you currently seeing a therapist/counsellor/psychotherapist/psychologist/psychiatrist?*

YesNo
Space for optional additional information about seeing a mental health professional

500 word limit0/500
Why do you want to attend for a Consultation or Assessment (Collaborative Autistic Identification)?

500 word limit0/500
Why do you think you might be Autistic?

500 word limit0/500
Describe your current/previous work/study

500 word limit0/500
What's your current living situation? who do you live with, alone? With a partner? With children?

500 word limit0/500
Give a little insight into your family history. Who raised you? Have you any siblings? What about relationships with family members growing up? Any Autistic family members you know of?

500 word limit0/500
Do you have any previous diagnoses? Maybe dyslexia, dyspraxia, ADHD? Anything mood, personality or mental health related? If yes, do you agree or disagree with them?

500 word limit0/500
What things make you feel happy and/or relaxed?

500 word limit0/500
What things make you feel anxious, irritated, frustrated?

500 word limit0/500
What is your ideal way of communicating with others? Do you prefer phone? Email? Face to face? Do you like others to repeat what they've said? Do you prefer information presented in a particular way or format? Do you prefer to talk to people individually? How do you feel about communicating in groups?

500 word limit0/500
How do you feel about 'small talk' and casual conversation? How do feel about sharing your experiences, thoughts and feelings with others?

500 word limit0/500
How do you experience non-verbal communication? Such as eye contact, body language, 'reading' other people, picking up on social cues, etc.?

500 word limit0/500
Do you feel you often 'mask' or 'camouflage' in certain situations? If you do this, how is this experience for you?

500 word limit0/500
Have you had to put a lot of effort over the years into learning to understand people and why they act how they do? Have you also put a lot of effort into acting a certain way in certain situations?

500 word limit0/500
How have you found developing and maintaining personal relationships throughout your life? Do you have many/few friendships? How important are they? are these things you have/would like to have?

500 word limit0/500
Medical history. Is there anything we need to consider as part of this process, e.g. have you ever had any illness or injury involving or impacting upon your brain? Do you have any genetic/chromosomal conditions? Are you currently taking any medication (please list if you are)?

500 word limit0/500
Mental health history. Have you ever experienced anxiety, low mood or any other mental health concerns? If so, to what extent? Have you ever linked in with a professional in relation to getting support with your mental health?

500 word limit0/500
The following question asks

"Have you ever experienced any significant events in your life that may have been traumatic (please only give as much detail as you feel comfortable providing)."

Please note:

We welcome you to share information with us in relation to significant events/experiences in your life that you feel are important to your assessment process, if you feel comfortable doing so. We will treat the information you share with us respectfully and confidentially. Please be reminded that there are some occasions when if past abuse/risk is reported to us we are legally obliged to report it to the relevant authority/agency, for example if there is ongoing risk to others. We would seek to discuss this with you first. If you have concerns about the limits of confidentiality, then please do discuss with your psychologist
Have you ever experienced any significant events in your life that may have been traumatic (please only give as much detail as you feel comfortable providing). . 

500 word limit0/500
Do you do anything with your hands or body to calm or regulate or to express excitement or joy. For example: Maybe you flap or clap your hands? Tap your fingers or twirl your hair? Pace or rock from foot to foot? Do you ever mimic sounds or make repetitive vocalisations? Did you do anything like this when younger?

500 word limit0/500
Describe how you feel when plans or your surroundings change, How do you feel about and deal with unpredictability or uncertainty?

500 word limit0/500
Do you have particular ways of doing things? for example do you prepare food a certain way or arrange your belongings in a certain way? Do you mind if other people do these things differently? How do you like to complete tasks at work/college?

500 word limit0/500
Write about the things you enjoy. Your hobbies and passions. What do they mean to you and how in-depth do you enjoy them? Do you ever get 'lost' in your interests and forget the outside world? or forget to do other things, e.g. eat or move around?

500 word limit0/500
From a sensory perspective, are there particular sensations you love or loathe? sounds/tastes/sights/textures/smells, movements? Do you seek out certain sensation and /or avoid others?

500 word limit0/500
Do you find it hard sometimes to recognise feelings or body sensations such as hunger or thirst? Do you ever forget to eat or drink? Or do you feel hunger or thirst very strongly?

500 word limit0/500
Is it sometimes hard to regulate your emotions? Do you experience frustration, meltdowns or shutdowns? Have you in the past?

500 word limit0/500
What's your experience of physical pain? Do you feel that you might be under or over-responsive to it?

500 word limit0/500
Thinking about someone who doesn't know you well, what words might they use to describe you?

500 word limit0/500
Thinking about someone who does know you well, what words might they use to describe you?

500 word limit0/500
Describe how you experience and understand your gender identity. Is it fluid or fixed? Is it something you have thought about a lot? Is it something you don't really think about at all?

500 word limit0/500
Have you ever experienced issues with sleep?

500 word limit0/500
Thinking about your experience of school, did you like or dislike it? What was OK? What was really difficult?

500 word limit0/500
Do you feel you have a strong sense of social justice and/or a dislike of artifice/lying? Do you find it difficult to understand unkindness, cruelty and injustice?

500 word limit0/500
Describe your attention/concentration skills. Do you find it hard to concentrate on some things? Yet sometimes you find yourself in a state of 'hyperfocus'? Do you notice details that others might not?

500 word limit0/500
How would you describe your organisation and planning skills? Do you find it easy or hard to tell how long a certain task will take?

500 word limit0/500
Have you read material or watched videos from Autistic people? Has anything resonated with your own experience? If you know other Autistic or neurodivergent people, do you feel a sense of connection or shared experience? Is communication and socialising easier with other Autistic people than with other people?

500 word limit0/500
Thinking about your dexterity and coordination, have you ever had difficulty with handwriting or holding a pen? What about doing delicate manual tasks? Ever been described as clumsy? How do you feel about sports/exercise in general?

500 word limit0/500
Feel free to share any other details you haven't covered elsewhere in this form. And don't worry if you think of something after you've submitted your form. You can always bring it up when you meet your psychologist.

500 word limit0/500

ADHD Experience Intake Form

The Adult Autism & ADHD Practice
Please only fill out this form if you have indicated that you wish to undergo assessment or consultation for ADHD in the dropdown menu above. If not, please proceed with the autistic experience intake form.

The purpose of this Intake Form is to gather information about you and how you experience the world. Your psychologist will use this information to help explore with you the question “Am I ADHD?”

If ADHD is identified by a psychologist (as it is in The Adult Autism Practice) it is not possible to access medication using the documentation we provide. If you are specifically seeking a formal ADHD identification in order to access medication, you will need to undertake an assessment/identification with a psychiatrist or other doctor who undertakes this work. We do not have a psychiatrist or other relevant doctor on our team. If you undertake an assessment with us and then choose later to go to a psychiatrist, they will ask fora full further assessment which you will need to pay for. This is standard for any person coming to them who has been identified by a psychologist previously. So please bear this in mind before deciding to go ahead.

Why filling in this form is helpful
- Many of our clients have expressed that they feel anxious that they won’t be able to get out everything that they want to verbally during their video sessions. Sending this information to your psychologist in writing means that you can give all the information you want to give, in the way you want to give it.
- There is a lot of information that we need to cover. Providing information in advance means that your online sessions will feel much less rushed as lots of important areas will already be covered.
- Sending the information to us in advance helps your psychologist know what the important areas are to focus on during your video sessions. After reading through this form, they will give you a plan in advance of each session of the areas you will be talking about.
- The process of writing this information down helps people focus their own thoughts, and see things in their life and past more clearly.
However, we know that filling in forms like these can be overwhelming!

If for any reason you would prefer to talk these things through instead of filling in this form that is aboslutely ok.

All you need to do in that instance is to fill in your name, email address, whether you are seeing a mental health professional, and the acknowledgements and signature at the end. You can then click on the submit button at the end of the form, and can proceed.

Some important points about filling in this form
- You do not need to fill this form in all at once. If you click the save button at the end of the form you will be emailed a link to your form with the bits you have completed included. You will need to sign up for a Jotform account to do this, but it should be a straightforward process.
- When answering, try to think about both your current experience and what you encounted in the past (childhood and adolescence).
- Once you are happy with what you have filled in, you can click submit.
- Your psychologist will read this form once they are assigned to do your assessment and you have chosen to go ahead with them specifically. This form may also be read by our Assistant Psychologist as part of the process of ensuring that you receive the right assessment for you, and that you are properly supported by the team.
- There is no ‘ideal’ amount of information to include. You can choose to include as little or as much in each area as you want.
- Please don’t worry about spelling or grammar.
- You do not need to write full sentences, feel free to add bullet points or single words/phrases.
- Some of the areas you will fill in in this form are related to ADHD. Others are not related to ADHD, but are there to help your psychologist get to know you and your history better.
- As mentioned previously, you do not need to fill in any section that you don’t want to. You can add something like “I’d prefer to talk about this in the session” or “I feel uncomfortable sharing this information.” Or just leave it blank!
- If you come to a question that you have already answered in a previous section, you don’t need to write it out again.
- While it looks like there is little space to write, don’t worry, once you start typing you will be able to write a lot. If you don’t have enough space you can send additional information to info@adultautism.ie.
Are you currently seeing a therapist/counsellor/psychotherapist/psychologist/psychiatrist?*

YesNo
Space for optional additional information about seeing a mental health professional
Why do you think you might be ADHD?

(e.g., what aspects of ADHD that you have read about resonate for you? Has anyone else ever suggested ADHD as an explanation for your experiences? When did you start to consider you might be ADHD?)0/400
What are your experiences with attention? Include information from between the ages of 5 to 12.

(e.g., do you finish/complete tasks before switching to another or tend to move between tasks without finishing them? Do you notice details in the environment that might take your attention away from a specific task? How do you find planning and organising tasks? Are you someone who focuses more on getting a task done quickly than accuracy? Do you enjoy long films/books or tend to find these boring? How is it following a conversation – do you lose track of what people are saying, or perhaps have lots of ideas to share?)0/400
Are you someone who is ‘always on the go’? Were you as a child?

(e.g., do you need to move, perhaps to help concentration? Do you prefer to move around rather than stay seated? Is your mind very active, e.g., feeling you have multiple ‘tabs’ open at the same time? Do you have multiple lines of thought going on concurrently? How is it waiting in queues or waiting for your turn to speak? Do you feel restless a lot?)0/400
How do you find working on a task with other people? Include information about now and about your childhood.

(e.g. are you more decisive than others? Can it be frustrating waiting for other people to finish speaking or complete a task?)0/400
How do you find following instructions? Now and in your childhood.

0/400
How do you find organising activities? Now and in your childhood.

(E.g., do you remember tasks you need to do/to attend appointments? Do you rely on structure/schedules to help you remember tasks/activities? Do you ever ‘double-book’ yourself?)0/400
How is your time-keeping? Now and in your childhood.

(E.g., Are you someone who likes/needs to be early, or do you often ‘run late’? Do you have a good sense of time, or tend to lose track of how much time has passed?)0/400
How do you make decisions? Now and in your childhood.

(E.g., Are you someone who make decisions quickly? Or do you find it challenging or perhaps ‘paralysing’ to make decisions? How do you approach decisions, e.g., do you use particular strategies to reduce how many decisions you need to make? Do you consider all options carefully, or act decisively based on initial information? How is it waiting for information that you might need to make a decision?)0/400
Have you previously or currently used any substances? What effect did they have for you?

(Some people who are ADHD might use various substances (e.g., alcohol, cannabis, cocaine, caffeine, etc.))0/400
How is your sleep? Now and in your childhood.

(E.g., is it difficult falling or staying asleep? Does anything help/make this worse?)0/400
How do you typically approach tasks, e.g., at school or work? Now and in your childhood.

Do you prioritise speed over accuracy? Do you read instructions quickly? Do you enjoy detailed tasks? Do you tend to put off boring/detailed tasks?0/400
Can you write a little about your interests? Now and in your childhood.

Do they tend to change a lot? Are you someone who embraces new things with passion? Do you get very absorbed in your interests?0/400
Do you find it hard to notice your strengths or to accept praise? Have you often been told that you do things ‘wrong’, or are ‘lazy’? Now and in your childhood.

0/400
Do any of the following influence how quickly or easily you complete tasks: Interest, urgency, competitiveness, novelty/newness? Now and in your childhood.

(e.g. needing a deadline to complete a task, or a tendency to prioritise new or exciting tasks)0/400
Can you tell us a bit about your memory or strategies that you use to recall information? Now and in your childhood.

0/400
Can you tell us a bit about your experience of feeling rejected? What is that like for you? How about your experience of being commended or praised for your work? Now and in your childhood.

0/400
Are you creative or imaginative? Do you often see connections or solutions that others don’t? Now and in your childhood.

0/400
What are your current and past experiences with relationships, friendships, and family/home life?

(E.g. Do you 'burn out' or tire of certain aspects of relationships? Quick to begin new relationships? End relationships and regret it later on? Maintain an equal share of tasks (e.g. making plans, keeping up with household chores etc.)? Experiences with food (e.g. binge eating, trying new foods, tired of familiar foods)? Experience of criticism (and praise)? Did/do you argue with friends, family, or siblings? Your experience managing money? Difficult to begin new relationships? Worried about punishment and criticism as a child? Avoid possible conflict or criticism? Did/do you require structure (e.g. a routine, schedule, reminders etc.) from parents, friends, or partners?) 0/400
Are you adventurous? Do you seek out new opportunities? Do you prefer to act on a ‘gut feeling’ or carefully collect information? Now and in your childhood.

0/400
Tell us about your current and past experiences at work.

(E.g. What kinds of roles do you prefer? Hands-on? Variety? Sameness? Own-business? Tire of roles/tasks quickly? Initially excel with new tasks, and then experience difficulties? Any strategies you have developed to 'compensate' (e.g. anxiety around forgetting things, setting reminders, doing tasks immediately as they arrive etc.)? Struggles with certain parts of training/education needed? Are you working in a role that reflects your achievements/education level? Is there a pattern of beginning new roles frequently? Experience of planning/organisation/administrative work? Ideal work-pace? Are you being recognized for your abilities? Any ideal structure that supports you? Flexible work hours? A strict routine? What tasks do you prefer doing at work? How is your experience of criticism? Relationship with co-workers?)0/400
How do you find socializing? How would you describe your communication 'style'? Now and in your childhood (e.g. 5 - 12 years old)

(E.g. Become bored or tired of certain topics? Switch between topics and avenues of discussion? What kinds of interactions are most enjoyable? Experience with long-term friendships/relationships? Are you first to initiate contact with others? Periods without reaching out? Remembering birthdays and events? Use reminders to help you with upcoming social events? Anxiety/difficulty asserting self and needs? Many or few friendships? Bullied or bullying? Difficulty accessing groups?)0/400
How would you describe your self-image? How about when you were younger? Are you a confident person? Do you find it easy to advocate for yourself?

(E.g. Uncertainty about self or difficulty trusting your abilities/judgement? Negative comments from others currently or in the past? Experience of criticism or failure? Is it difficult to start new things because of this (e.g. relationships, courses, jobs etc.)? Are you a 'perfectionist' or hold yourself to a high standard?)0/400
What kind of hobbies and interests do you have? Do your experiences change the way you interact with them? Include information from now and in your childhood.

(E.g. Can you 'wind-down' or relax quickly? Do you prefer engaging activities, such as sports, video games etc.? Need to move around to relax? Beginning new hobbies or tasks? Finish what you have started? Strategies to help you focus (e.g. listening to music while reading or using subtitles while watching TV)? Always busy/agreeing to plans/projects/events? Do you have several activities 'on the go' at once? Do you become focused on certain activities? Seek out new experiences? Accidents because of recklessness? Do you take risks?)0/400
Tell us about your current and/or past experiences with education.

(E.g. Do you feel your educational achievements reflected your abilities/potential? Better in certain areas (exams, practical assignments, essays, etc.)? Ability to concentrate? Strategies to help you focus (e.g. moving around, fidgeting, doodling etc.)? How is your organisation (remembering certain items, your schedule etc.)? Repeat classes? Focusing in class? Repeat/re-read certain sections of text or activities? Finishing up on tasks (spelling and grammar etc.)? Put in more effort to achieve results? Did you need to quit or stop education? Your experience with homework? Access to additional supports in school? Behavior or or concentration commented on? Was this different at home vs. school? Any aspects of structure (e.g. routines, clearly defined classes, time-limits etc.) that helped you achieve? Are there any skills/strengths you have that aided any challenges with education?)0/400
Part 1 of 3: Experiences of Interest-based Attention
For each of the questions below, select either:

“Yes, this is like me” - Please give examples from at least two contexts of your life and experiences. You do not need to provide information on areas that are not relevant to you. Each area has suggested areas to consider but include any other details you feel are important.

or

“No, this is not like me” - If no, you can move onto the next question.

There are plenty of questions under each question to prompt you, but you do not need to address all of them.

Also, remember that you can save as you go along, and can come back to the form before submitting.
1a. Do you process information and complete tasks faster when they are related to your interests?
1b. Do you have a preference for working with “big picture" thinking instead of minor details, which might lead to inadvertent errors?
1. In Education

Things to consider: What were common themes in your school reports? (e.g., working too quickly, finding it harder to focus on topics that were not of interest). What, if any, discrepancies were there between your ability, and written work/test results? (e.g., did you, caregivers, or teachers feel you were not ‘not meeting your full potential’?). Did you find it difficult to check over tasks, for example fixing the spelling and grammar Did you hand homework in on time? (If yes, what helped you with this?) Did you always “cram” information at the last minute for tests or exams? What supported you to complete tasks? (e.g., did you need a sense of urgency to meet deadlines? Supervision/prompting from a caregiver?).0/400
1. In Work

Things to consider: What is your ideal work pace? (e.g., rapid turnover of work/tasks? Being able to set your own pace?) Do you enjoy detailed or bigger picture tasks? In teamwork, are you faster at understanding information and problem solving compared to others? Do you need a deadline to complete a task? Do you notice small details or minor output mistakes? Are there any apps or technology that support you in checking for mistakes and errors?0/400
1. Life and House Admin/Chores

Things to consider: Do you read instructions quickly? How do you manage post and household bills? What supports you doing this? Do you have a system? (e.g., paying all bills by direct debit) What about managing online shopping returns? Do you miss return deadlines? How did you find filling out the forms we sent you/ any other forms? How do you approach chores? (e.g., do you prefer getting chores done as quickly as possible, especially less interesting tasks? Do you find it hard to get going with chores?).0/400
1. Social Situations

Things to consider: How do you prefer to communicate with your friends? Do you check/edit messages before you send them? Do you tend to make errors and need to check (even if you do not actually check).0/400
1. Hobbies and Downtime

Things to consider: How do you manage subscriptions and memberships? (e.g., do you remember to cancel free trials?) How do you keep track of plans or appointments? (e.g., physical diary; phone calendar to send alerts) Do you ever miss appointments or meeting friends? If so, what gets in the way? (e.g., forgetting, time management, getting ‘stuck’ in inertia).0/400
1. Impact on Relationships

0/400
2a. Do you enjoy longer periods of sustained attention/hyperfocus driven by any of these things: Interest? Competitiveness or fun? Novelty? Rewards?
2b. Do you find that your interest is not sustained (or sustained more rarely or only with great effort) when these are not present?
2. In Education

Things to consider: What subjects did you enjoy? What did you do well in? Did you enjoy being competitive at school?0/400
2. In Work

Things to consider: Is your work linked to your interests in any way? Do you prefer more structured jobs (e.g., clear and predictable career progression within an organisation) or working across different settings and roles (e.g., self-employment; working freelance). What kind of roles do you prefer in work? Hands-on? Variety or sameness? Own business? Do you seek new employment opportunities frequently? Is this driven by seeking new and interesting roles? Are you initially excited with new tasks and then experience difficulties completing them once they are no longer novel? How do you respond to emergencies or stressful situations at work?0/400
2. Life and House Admin/Chores

Things to consider: What is your experience with food, do you enjoy trying new foods or familiar foods? Do you find faster or more creative ways of doing things at home compared to others in the household? Do you have a preference for smaller, more immediate rewards/gratification?0/400
2. Social Situations

Things to consider: How do you like to spend your spare time? Do your friends or family share the same preferences? What things do you find fun to do? (e.g., meeting friends; sports; drinking alcohol etc.) Do these activities involve novelty and/or excitement? How do you relax? (e.g., do you find high energy sports more relaxing than a quieter activity such as reading?)0/400
2. Hobbies and Downtime

Things to consider: Do you become very focused on certain activities? Do your interests and hobbies change often? Do you prefer to experiment with lots of different hobbies or focus on completing just one project at a time? Do you prefer leaving activities for a bit and then coming back to them?0/400
2. Impact on Relationships

0/400
3a. Do others interpret or report that you don’t seem to be listening when you are?
3b. When you are in hyperfocus, do you find yourself staying focused on the current task/activity rather than on another person talking?
3c. Do you experience being more focused on your internal thoughts rather than another person talking?
3d. Do others tell you that you don’t seem to be listening when they are speaking to you directly?
3. In Education

Things to consider: Did you find it easier to listen to/process spoken information in some subjects rather than others? Did teachers comment on fluctuations in your listening across different subjects?0/400
3. In Work

Things to consider: Do you notice you sometimes haven’t been following conversations / instructions/ meetings? Do you ever feel that you have “zoned out” and then repeated something someone may have just said? How do you experience staff meetings, conferences, or training events?0/400
3. Life and House Admin/Chores

Things to consider: How do you experience listening/processing spoken communication when you are completing tasks at home? What happens to your listening/processing spoken communication when you are multitasking?0/400
3. Social Situations

Things to consider: Do friends or family give you feedback that you don’t seem to be listening? Does how interested you are impact on how you manage following conversation? (e.g., do you find it harder to follow conversations about topics you are not interested in?) Are there times when you don’t recall conversations that friends/family report have taken place? How does this impact relationships (e.g., causes conflict, tension).0/400
3. Hobbies and Downtime

Things to consider: Do you prefer reading books or listening to audiobooks? Can you follow audiobooks and stay focused? How do you find watching TV/films/boxsets? Can you follow dialogue? Do you use subtitles? (e.g., to support auditory processing and concentration).0/400
3. Impact on Relationships

0/400
4a. Do you find it hard to follow instructions and/or complete tasks when it is difficult to focus (e.g., if you’re not interested in a task)?
4b. Do you prefer following instructions if they are presented in short, coherent, and concrete steps?
4c. Do you find it hard to follow instructions and finish tasks when they are not meaningful or rewarding?
4d. Do you prefer to cycle in and out of creative hobbies and projects rather than completing them in a linear way?
4. In Education

Things to consider: Did you benefit from extra explanations/ talking through instructions with peers? Did you struggle with certain steps of learning tasks?0/400
4. In Work

Things to consider: Do you enjoy shorter and more concrete tasks? How do you experience following instructions at work? What supports you with this? (e.g., written information documenting task steps; written summaries of meeting objectives/outcomes).0/400
4. Life and House Admin/Chores

Things to consider: How do you find setting up new household equipment and technology? What supports you with this? Is building flat-pack furniture something that you find easy, manageable, or difficult? What aspects do you find easy/difficult? (e.g., prefer visual information; miss steps; misplace screws etc.).0/400
4. Social Situations

Things to consider: How do you manage with following instructions during social activities?0/400
4. Hobbies and Downtime

Things to consider: How do you experience following long instructions for setting things up such as a new computer or game? How do you prefer to learn new things? (e.g., trial and error and working it out as you go; reading instructions fully before starting). Are you someone who ‘bounces’ between different interests? Do you get enthused by a new interest and immerse yourself fully, but then move onto a new interest? Do you tire or become bored of certain topics? How long do your interests tend to last?0/400
4. Impact on Relationships

0/400
5. For this section, think about:
- Your experience of organising tasks and activities in different contexts.
- Your experience of time awareness and time management.
- Your experience of money management.
Please expand under the headings below.
5. In Education

Things to consider: How did you find navigating around classrooms and buildings? e.g., could you find the right classroom at the right time? Did you remember the books/materials you needed for that class? How did you find packing bags and remembering kit? Did you need support with this? How did you plan coursework and revision? Are you better in certain areas, for example, exams, practical assignments or essays?0/400
5. In Work

Things to consider: What is your experience of organisation/administrative work? What supports you with this type of task? Is there an ideal work structure that supports you? Do you like flexible hours at work or a strict routine? How do you find planning projects? If relevant, how do you find organising work events and trips? (Differentiate work social events vs. booking large meetings etc.).0/400
5. Life and House Admin/Chores

Things to consider: How do you manage with planning and organising meals? How do you manage regular tasks such as washing dishes, doing laundry, cleaning worksurfaces? How do you organise frequent tasks such as shopping? Do you have a ‘system’ for this or buy things when you run out? Do you prefer online food shopping or in person? For what reasons? If relevant, how do you manage home maintenance tasks? What are things that are tricky, or that help with this? (e.g., having to contact landlord to arrange repairs by phone might be a barrier). How do you get on finding tradespeople to do home repairs? What are the barriers? How do you manage your finances? Are you someone who likes/needs to be early, or do you often run late? Do you have a good sense of time, or do you tend to lose track of how much time has passed?0/400
5. Social Situations

Things to consider: Are you someone who plans or organises social events and parties? If yes, how do you approach this? (e.g., detailed plans in advance; spontaneously arrange an event). What social activities do you enjoy? How do you keep on top of them? e.g., rely on phone prompts to remind; do you ever double-book yourself? Or forget to meet people?0/400
5. Hobbies and Downtime

Things to consider: How do you approach planning your free time? How do you approach organising trips to places of interest (gigs, festivals, galleries)? Are you someone who enjoys holidays? If so, how do you approach organising holidays? Are there some areas that you find easier/prefer doing to others?0/400
5. Impact on Relationships

0/400
6a. Is it hard to choose and/or start tasks when they do not interest you?
6b. Do you prefer/tend to delay tasks that are not meaningful or enjoyable?
6c. Do you experience difficulty getting started on unrewarding tasks?
6. In Education

Things to consider: What subjects did you not enjoy and why? How did you manage with those?0/400
6. In Work

Things to consider: Which tasks do you prioritise, and which ones do you delay? Do you tend to put off boring/detailed tasks? Do any work tasks make you feel anxious or stressed? 0/400
6. Life and House Admin/Chores

Things to consider: Is there any life or household chores you find easier/more doable than others? Are there tasks you find confusing, boring or painful? In your household, how are tasks distributed? (e.g., does everyone take an equal share?) Do you rotate tasks? (e.g., having a rota for cleaning different rooms vs. doing tasks when you notice they need doing). 0/400
6. Social Situations

Things to consider: Are there any events/ activities you would prefer not to attend? Do you burn out or tire of certain aspects of relationships? Have you noticed any pattern in your relationship history? (e.g., are you someone who ends a relationship from a quick decision but regret it later on?).0/400
6. Hobbies and Downtime

Things to consider: How are you at beginning new hobbies or tasks that you aren’t interested in? What do you find boring and unenjoyable that many others seem to enjoy?0/400
6. Impact on Relationships

0/400
7a. Do you spend lots of time looking for items?
7b. Do you have to spend money replacing items you’ve lost?
7. In Education

Things to consider: Was your bedroom organised and neat or more messy? Did parents/teachers provide structure (e.g., special places for keeping your things safe)? Did you spend lots of time looking for things?0/400
7. In Work

Things to consider: How do you manage your belongings and items in the workplace? How do you keep track of equipment?0/400
7. Life and House Admin/Chores

Things to consider: Do you need special places that you must keep certain things? Are you happy for people to borrow your things (e.g. keys/ chargers)? If not, why? What issues does it cause for you? Do you spend much time looking for things? Do you lose things frequently and have to replace them? Do you spend much time looking for things?0/400
7. Social Situations

Things to consider: Do you tend to leave items behind? Do you have to return to places to collect forgotten items? Do you have multiple items in different houses (e.g., at partner’s/parents depending on age)? How do you keep track of tickets and items for events (such as talks, gigs, festivals)?0/400
7. Hobbies and Downtime

Things to consider: How much time do you have to spend trying to locate where the things you need for your hobbies are? Does this end up taking time away from engaging in the interest itself? Do you end up spending time searching for new items to buy related to your interests? (e.g., going online to buy a specific item you need, but end up spending long periods of time searching online for related items).0/400
7. Impact on Relationships

0/400
8a. Is your attention often spread across a wide range of things in the environment, rather than having very focused attention on one or a few things?
8b. Do you experience your attention being directed by external stimuli (e.g., things around the room, in the environment, other people)?
8c. Do you experience your attention being directed by internal stimuli (e.g. 100s of thoughts at one time)?
8. In Education

Things to consider: How did you experience focusing in classes? Have you ever had to repeat classes? Was your behaviour or concentration ever commented on in school?0/400
8. In Work

Things to consider: Are there any aspects of structure in your workplace (e.g. routines, clearly defined time limits) that help you to complete tasks/do well? Do you need to repeat or reread certain sections of text or activities? Why might this be? (e.g., reading so quickly you missed the details; there was too much information to process in one go; too much text to process properly) Are you creative or imaginative? Do you often see connections or solutions that others don’t?0/400
8. Life and House Admin/Chores

Things to consider: Do you have multiple household activities and chores running concurrently? How long does it take you to get ready and leave the house? Do you have a ‘system’ in place for approaching regular tasks? (e.g., packing work/gym bag in advance).0/400
8. Social Situations

Things to consider: What kind of interactions are most enjoyable for you? Do you switch between topics and avenues of discussion? Do you have many or a few friendships? Are you always busy/agreeing to plan/projects/events?0/400
8. Hobbies and Downtime

Things to consider: Is your mind very active (e.g. feeling you have multiple tabs open at the same time)? Do you experience a mental peace or mindfulness during any activities? Do you have several hobbies on the go at once? Do certain topics spark new ideas?0/400
8. Impact on Relationships

0/400
9a. Do you find it difficult to remember information related to daily activities?
9b. Do you find it easier to respond to items and people in your immediate environment?
9. In Education

Things to consider: Did you require structure (e.g. written routines, schedules and checklists to remember things for school)? Did parents, friends or partners remind you of events and deadlines?0/400
9. In Work

Things to consider: Do you use any strategies to help you remember work tasks, meetings and events? Do you prefer to complete tasks immediately as they arrive?0/400
9. Life and House Admin/Chores

Things to consider: Have you developed strategies to compensate for forgetting (e.g. anxiety around forgetting things, setting reminders)? Do you take medication? How do you remember to take it? (e.g., alarm on phone blister packs). How do you manage requesting regular medication (e.g., forget to request meds so run out; using diarised reminders; having blister packs so the pharmacy requests meds for you). How do you remember tasks you need to do/to attend appointments? Do you ever double book yourself? How do you manage household items such as loo roll, washing tablets needed for everyday activities?0/400
9. Social Situations

Things to consider: Are you typically the one to initiate contact with others? Are there long periods when you don’t contact friends and family? How are you at remembering birthdays and events? Do you use reminders to help you with upcoming social events?0/400
9. Hobbies and Downtime

Things to consider: Do you find items in unexpected places?0/400
9. Impact on Relationships

0/400
Part 2 of 3: Experience of Intensity of Attention, Pacing and Movement Differences
For each of the questions below, select either:

“Yes, this is like me” - Please give examples from at least two areas of your life and experiences. You do not need to provide information on areas that are not relevant to you. Each area has suggested areas to consider but include any other details you feel are important.

or

“No, this is not like me” - If no, you can move onto the next question.

There are plenty of questions under each question to prompt you, but you do not need to address all of them.

Also, remember that you can save as you go along, and can come back to the form before submitting.
1. Does using objects (e.g., fidget items, chewing pens) or moving your body (e.g., tapping feet) help your concentration?
1. In Education

Things to consider: Did you benefit from using any strategies (such as fidget item, doodling) to help you concentrate? How was it if you were prevented from doing these things? Did you like to change your sitting position frequently when doing your homework? Where would you do you work? (e.g., on the floor; at a desk, on the bed). Did you choose where you studied so you could move easily?0/400
1. In Work

Things to consider: Do you need to move to support your concentration? Do you feel able to move freely in your workplace? Does tapping or drumming your fingers, moving your feet or moving your chair etc. support you to focus? If you work from home, are there additional things that you do to support your concentration? (e.g., that you aren’t able to do in an office, such as sitting cross-legged, rocking as you work).0/400
1. Life and House Admin/Chores

Things to consider: Does chewing on pens or gum help you to concentrate? Do you prefer to do admin in a more interesting place, such as a cafe? Does singing to music or listening to a podcast help you focus on driving or other tasks? Does music help motivate you to get going with tasks?0/400
1. Social Situations

Things to consider: Do you find it easier to engage socially when you are enjoying an active time, such as going for a walk, playing sport together?0/400
1. Hobbies and Downtime

Things to consider: Do you like to ‘double up’ on hobbies, such as watching TV while knitting, or doing Sudoku while listening to a podcast?0/400
1. Impact on Relationships

0/400
2. Do you prefer leaving your seat in contexts where the environment typically requires being seated (e.g. a lecture, the cinema, a meeting)?
2. In Education

Things to consider: Did you prefer subjects where you could move around? Did you like to leave the table during and immediately after eating? Did you find reasons to leave the classroom? Was this to seek a movement break?0/400
2. In Work

Things to consider: Do you benefit from frequent movement or social media breaks? Do you prefer to stand, walk or change position when working? How do you experience meetings? Does moving around help you stay focused?0/400
2. Life and House Admin/Chores

Things to consider: Do you prefer chores that enable you to move around? Is it easier getting going with tasks that require movement (e.g., cleaning floors) rather than sitting (e.g., going through bank statements)?0/400
2. Social Situations

Things to consider: Do you enjoy going to the cinema, concerts, plays or theatre? If so, how do you experience staying seated for long periods of time? How do you experience restaurants, in terms of staying seated to eat?0/400
2. Hobbies and Downtime

Things to consider: Do you prefer hobbies and activities that incorporate movement? How do you like to watch TV/films at home? e.g. whilst moving around, sitting on the floor etc.0/400
2. Impact on Relationships

0/400
3. Do you or did you feel a strong urge to move around or feel restless in situations like social gatherings or settings where the context requires staying or standing still?
3. In Education

Things to consider: How did you spend break times? What did you enjoy doing after school/ in the evenings?0/400
3. In Work

Things to consider: Do you choose activities and environments where movement is expected/accepted? Do you choose roles and careers that enable you to move a lot physically? e.g., avoiding office-based jobs in favour of working outside/in a physical role.0/400
3. Life and House Admin/Chores

Things to consider: How does it feel if you are unable to change position or have a break?0/400
3. Social Situations

Things to consider: Do you prefer social activities that involve a lot of movement? What kind of venues and environments do you choose to socialise in?0/400
3. Hobbies and Downtime

Things to consider: How do you experience boredom? Do you like having lots of plans or no plans for your free-time or holidays?0/400
3. Impact on Relationships

0/400
4. Do you or did you prefer to talk or make noise in social settings in which the context requires being quiet (e.g. at the cinema/theatre; watching movies at home with friends)?
4. In Education

Things to consider: Did you enjoy engaging enthusiastically and out loud with tv and films? Did teachers or comment on the amount and volume of your talking in class?0/400
4. In Work

Things to consider: Do you enjoy singing or humming while working? Is it helpful to give a ‘running commentary’ on what you’re doing?0/400
4. Life and House Admin/Chores

Things to consider: Are you able to complete household chores like cooking and planning in company of others? Or does talking to them take your focus away from those tasks?0/400
4. Social Situations

Things to consider: Are there times when you really want to share ideas/thoughts and do so even when there is an expectation for staying silent? Do you sometimes forget not to talk during films, plays or shows?0/400
4. Hobbies and Downtime

Things to consider: Do you need quiet while you are completing your hobbies, or do you prefer to have music and noise around you? Does this vary according to the activity, or your energy levels?0/400
4. Impact on Relationships

0/400
5a. Do you, or did you experience often being on the go/”driven by a motor”/ having a lot of energy?
5b. Do you or did you experience of high or “limitless” energy levels in the mind?
5. In Education

Things to consider: Did you find ways to burn off energy when you could during and after school? How did you experience sports? Did you do lots of extra-curricular activities?0/400
5. In Work

Things to consider: Do others struggle to keep up with your thoughts and ideas? Do you work faster than your colleagues? Do you like to play sport or burn off energy during the working day?0/400
5. Life and House Admin/Chores

Things to consider: Can you complete lots of tasks at one time and do them faster than other people? Do you prefer to get things done before you can relax? Do you experience energy crashes/burnouts after a period of busyness?0/400
5. Social Situations

Things to consider: Do you seek out new experiences? Are you adventurous?0/400
5. Hobbies and Downtime

Things to consider: Do you ever have accidents because of recklessness or approaching tasks too quickly? Can you wind down or relax quickly? Do you need to move around to relax Do you prefer engaging activities such as sports/video games etc?0/400
5. Impact on Relationships

0/400
6. Do you or did you experience any of the following in conversations including: Excitability and passion? Increased volume and pace of speech? Tangents and variety in thoughts?
6. In Education

Things to consider: Did teachers comment on the volume and frequency of your talking? Did you invest a lot of time in talking with friends?0/400
6. In Work

Things to consider: Have you chosen tasks/careers that allow a lot of talking and social interaction? Do you spend lots of time talking to colleagues and run out of time to complete tasks?0/400
6. Life and House Admin/Chores

Things to consider: Do you enjoy talking to shop assistants, people bringing deliveries and other people you meet during your tasks?0/400
6. Social Situations

Things to consider: How does time pass when you are talking to friends and family? Do others struggle to follow your thoughts and conversation? Does it feel that you see the ‘point’ faster than other people do? Do people give you feedback that you can be overheard when you don’t intend this?0/400
6. Hobbies and Downtime

Things to consider: Do you enjoy deep conversations about your passions and interests? Do you tend to talk at length about passions (e.g., info dumping)?0/400
6. Impact on Relationships

0/400
7a. Do you or did you experience faster processing speeds in conversation than other people?
7b. Do you often recognise questions and respond to them before they are finished?
7c. Do you often complete others’ sentences?
7. In Education

Things to consider: Did you often understand a question before it had been completed? Did you answer questions before they had been finished?0/400
7. In Work

Things to consider: Do you consider all options carefully, or act decisively based on initial information? Do you use strategies to reduce how many decisions you need to make? How is it waiting for information that you might need to decide? When working on task with other people, are you more decisive than others?0/400
7. Life and House Admin/Chores

Things to consider: Do you prefer to act on gut feeling or carefully collect information?0/400
7. Social Situations

Things to consider: Do you take what others consider to be risks? Please give examples. Do you tend to say things that later with reflection you might have said differently?0/400
7. Hobbies and Downtime

Things to consider: Are you someone who makes decisions quickly in your hobbies or in games?0/400
7. Impact on Relationships

0/400
8. Do you or did you prefer to engage in tasks straight away and/or without having to wait for other people or information?
8. In Education

Things to consider: How was your safety awareness? How were you waiting for breaks and to leave at the end of the day? How were you taking turns in games?0/400
8. In Work

Things to consider: How do you feel waiting for other people to finish speaking or complete a task? How do you experience waiting for necessary work information or data from others? How do you feel in busy canteens or cafes during a working day?0/400
8. Life and House Admin/Chores

Things to consider: How is it waiting in queues? How is it waiting in traffic?0/400
8. Social Situations

Things to consider: How is it waiting to speak? What might the challenges be? (e.g., wanting to share ideas and not wait; finding it hard to judge when it’s your turn to speak). How do you feel in busy venues or places when you can’t get served?0/400
8. Hobbies and Downtime

Things to consider: Do you prefer media where the pacing can be controlled (sped up or slowed down)? Do you tire of activities or games where things are taking too long? How do you experience media buffering?0/400
8. Impact on Relationships

0/400
9a. Do you or did you find that your interest-based attention and speed of processing sometimes influences social situations?
9b. Do you experience differences when engaging socially due to passion/enthusiasm?
9c. Do you have a preference for directness and honesty?
9d. Do you dislike waiting and turn-taking?
9. In Education

Things to consider: How did you join in games and activities? Was this tricky? For what reasons? Did you get into arguments with friends or families for taking their things?0/400
9. In Work

Things to consider: What happens when you have something very important to say and think you might forget it? Do you take on a lot of extra work that should be done by other people? Do you prefer to be involved in what your team/colleagues are doing? Do you feel the need to intervene or correct unfairness?0/400
9. Life and House Admin/Chores

Things to consider: Do you take on more than you can manage?0/400
9. Social Situations

Things to consider: Do you find yourself finishing other people’s sentences? Do you argue with friends, family or siblings? Do you take steps to avoid possible conflict or criticism? Were you ever bullied or did bullying? Do you experience anxiety or difficulty asserting yourself and needs?0/400
9. Hobbies and Downtime

Things to consider: Do you prefer to get involved with other people’s experiences? Does taking on too much of other people’s problems and difficulties use up spare time? How do you interact with social media?0/400
9. Impact on Relationships

0/400
Part 3 of 3: Additional experiences
Current diagnostic criteria captures only a limited part of ADHD experience. This section asks about additional experiences. Please complete sections that feel relevant to you. If a section is not relevant for you, move onto the next section.
1. Some people who are ADHD might use various substances (e.g., alcohol, cannabis, cocaine, caffeine, etc.) Have you previously or currently used any substances? What effect did they have for you?

0/400
2. How is your sleep? (e.g., is it difficult falling or staying asleep? Does anything help/make this worse?)

0/400
3. Do you find it hard to notice your strengths or to accept praise? How is it being commended for your work?

0/400
4. Can you tell us a bit about your memory or strategies that you use to recall information?

0/400
5. Can you tell us a bit about your experience of feeling rejected? What is that like for you?

0/400
6. How would you describe your self-image? How about when you were younger? Are you a confident person? Are you a 'perfectionist' or hold yourself to a high standard?

0/400
7. Medical history. Is there anything we need to consider as part of this process, e.g. have you ever had any illness or injury involving or impacting upon your brain? Do you have any genetic/chromosomal conditions? Are you currently taking any medication (please list if you are)?

0/400
8. Mental health history. Have you ever experienced anxiety, low mood or any other mental health concerns? If so, to what extent? Have you ever linked in with a professional in relation to getting support with your mental health? Mental health history (optional)

0/400
9. Do you have any previous diagnoses? Maybe dyslexia, dyspraxia, Autism? Anything mood, personality or mental health related? If yes, do you agree or disagree with them?

0/400
The following question asks:

"Have you ever experienced any significant events in your life that may have been traumatic (please only give as much detail as you feel comfortable providing)."

Please note:

We welcome you to share information with us in relation to significant events/experiences in your life that you feel are important to your assessment process, if you feel comfortable doing so. We will treat the information you share with us respectfully and confidentially. Please be reminded that there are some occasions when if past abuse/risk is reported to us we are legally obliged to report it to the relevant authority/agency, for example if there is ongoing risk to others. We would seek to discuss this with you first. If you have concerns about the limits of confidentiality, then please do discuss with your psychologist.
10. Have you ever experienced any significant events in your life that may have been traumatic (please only give as much detail as you feel comfortable providing).

0/400
11. Describe how you experience and understand your gender identity. Is it fluid or fixed? Is it something you have thought about a lot? Is it something you don't really think about at all?

0/400
12. Describe your current/previous work/study

0/400
Medication*

I am aware that if ADHD is identified, I will not be able to access medication with the documentation provided.
Consent*

I consent to undertaking further ADHD identification with The Adult Autism Practice. All other terms of consent are the same as previously signed in my autism identification consent. I am aware of all other terms and information in the consent document I have previously signed.

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Name*
Completion date*

DayMonthYear
TOTAL ALL ITEMS
TOTAL R
TOTAL W
TOTAL P
TOTAL F
TOTAL ALL ITEMS MINUS R
IMPORTANT - PLEASE READ THIS FIRST

This form has 34 statements about how you have been OVER THE LAST WEEK.

Please read each statement and think how often you felt that way last week. Then choose an answer from the drop-down, which best fits this feeling.
1 I have felt terribly alone and isolated*
2 I have felt tense, anxious or nervous*
3 I have felt I have someone to turn to for support when needed*
4 I have felt OK about myself*
5 I have felt totally lacking in energy and enthusiasm*
6 I have been physically violent to others*
7 I have felt able to cope when things go wrong*
8 I have been troubled by aches, pains or other physical problems*
9 I have thought of hurting myself*
10 Talking to people has felt too much for me*
11 Tension and anxiety have prevented me doing important things*
12 I have been happy with the things I have done*
13 I have been disturbed by unwanted thoughts and feelings*
14 I have felt like crying*
15 I have felt panic or terror*
16 I made plans to end my life*
17 I have felt overwhelmed by my problems*
18 I have had difficulty getting to sleep or staying asleep*
19 I have felt warmth or affection for someone*
20 My problems have been impossible to put to one side*
21 I have been able to do most things I needed to*
22 I have threatened or intimidated another person*
23 I have felt despairing or hopeless*
24 I have thought it would be better if I were dead*
25 I have felt criticised by other people*
26 I have thought I have no friends*
27 I have felt unhappy*
28 Unwanted images or memories have been distressing me*
29 I have been irritable when with other people*
30 I have thought I am to blame for my problems and difficulties*
31 I have felt optimistic about my future*
32 I have achieved the things I wanted to*
33 I have felt humiliated or shamed by other people*
34 I have hurt myself physically or taken dangerous risks*

Should be Empty:

The Adult Autism and ADHD Practice Intake Form

What do you want to attend for?

Your Information

General Practitioner's Details

Emergency Contact Information

Private Health Insurance

Consent to Contact Adult Mental Health

Adult Mental Health (AMH) Information

Consent to Receive Communication

Consent

Autistic Experience Intake Form

ADHD Experience Intake Form

Part 1 of 3: Experiences of Interest-based Attention

Part 2 of 3: Experience of Intensity of Attention, Pacing and Movement Differences

Part 3 of 3: Additional experiences

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