Patient Name *

First Name

Last Name

Phone

(###)

###

####

Patient Date of Birth *

MM

DD

YYYY

Reason for referral: *

Interested in learning about ADHD medication, not yet ready to start a trial

Never been prescribed ADHD medication in the past, but now ready to start a trial

Have been prescribed ADHD medication in the past, currently not taking, ready to re-start

Currently taking ADHD medication, not working well, wanting to change medication

Currently taking ADHD medication which is working well, needing a new prescriber to take over

Other

No

What is patient diagnosed with? *

ADHD, Inattentive Subtype (F90.0)

ADHD, Hyperactive/Impulsive Subtype (F90.1)

ADHD, Combined Subtype (F90.2)

ADHD, Other Type (F90.8)

Is the patient diagnosed with any other mental health or medical conditions? *

No other mental health or medical conditions.

Depression

Anxiety

Bipolar disorder

Schizophrenia

Other psychiatric diagnosis

Cardiac issues (high blood pressure, etc.)

Seizure disorder

Other medical diagnosis

Is the patient currently using any medications for ADHD or other mental health issues? *

No

Yes

Has the patient ever been prescribed medications for ADHD or other mental health issues in the past? *

No

Yes

Eligibility Confirmation *

I confirm that I have read the eligibility criteria listed above and that the patient meets these requirements.