Fillable VCH ADULT ADHD REFERRAL FORM (Vancouver Coastal Health)

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VCH ADULT ADHD REFERRAL FORM (Vancouver Coastal Health)

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VCH ADULT ADHD REFERRAL FORM
Client: DOB (m/d/y) PHN
Address: City:
Home #: Cell: Email:
MSP:
Referring Physician :
Phone:
Fax:
Describe current ADHD Symptoms and ADHD-related Impairment:
Reason for Referral:
Current Medications:
Other Psychiatric Conditions and current Treatment (medication/therapy):
Current Substance Misuse (please describe) and current Treatment:
MEDICAL
We require physical examination and medical history within the last 6 months to rule out organic
causes of
ADHD-like symptoms:
Date Completed: Completed by:
Referral to our Clinic must include ASRS, PHQ-9 and GAD-7: These are attached below
Physician Signature Date:
VCH Adult ADHD Clinic
HOpe Centre
1337 St. Andrews Avenue
North Vancouver, BC,
V7LOB8
Tel: 604.9845000 ext. 5163
Fax: 604.983.6073
ADHDAdultClinic@VCH.ca
****Please note we are unable to accept/process incomplete referrals
Positive Cardiac History (attach current treatment and diagnostic information)
Chronic Medical Conditions (Please List)
Patient consent contained to release documents and share information with ADHD Clinic
ADHD Assessment
ADHD Re-Assessment
Medication Adjustment
Adult ADHD Self-Report Scale (ASRS)
PHQ-9/GAD-7
Referring Physician is aware that the client will return to their care for ongoing management within
the context of a collaborative care model
Client is between the ages of 19-35 (please note, clients must be within this age range to be eligible for services)
To your knowledge, does this client have a current/recent diagnosis of ADHD?
Yes
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PART A
How often do you have trouble wrapping up the final details of a project, once the
challenging parts have been done?
How often do you have difficulty getting things in order when you have to do a task
that requires organization?
How often do you have problems remembering appointments or obligations?
When you have a task that requires a lot of thought, how often do you avoid or delay
getting started?
How often do you fidget or squirm with your hands or feet when you have to sit down
for a long time?
How often do you feel overly active and compelled to do things, like you were driven
by a motor?
PART B
How often do you make careless mistakes when you have to work on a boring or difficult
project?
How often do you have difficulty keeping your attention when you are doing boring or
repetitive work?
How often do you have difficulty concentrating on what people say to you, even when
they are speaking to you directly?
How often do you misplace or have difficulty finding things at home or at work?
How often are you distracted by activity or noise around you?
How often do you leave your seat in meetings or in other situations in which you are
expected to stay seated?
How often do you feel restless or fidgety?
How often do you have difficulty unwinding and relaxing when you have time to
yourself?
How often do you find yourself talking too much when you are in social situations?
When you’re in a conversation, how often do you find yourself finishing the sentences of the
people you are talking to, before they can finish it themselves?
How often do you have difficulty waiting your turn in situations when turn taking is required?
How often do you interrupt others when they are busy?
© World Health Organization 2003 All rights reserved. Based on the Composite International Diagnostic Interview © 2001
World Health Organization. All rights reserved. Used with permission. Requests for permission to reproduce or translate —
whether for sale or for noncommercial distribution—should be addressed to Professor Ronald Kessler, PhD, Department of
Health Care Policy, Harvard Medical School, (fax: +011 617-432-3588; email: ronkadm@hcp.med.harvard.edu).
Never Rarely Sometimes Often
Very
often
ADULT ADHD SELF-REPORT SCALE (ASRS-V1.1) SYMPTOM CHECKLIST
Client:
PRINT
Jan 11, 2021
PHQ-9 & GAD-7
Lions Gate Hospital
ADULT A
DHD CLINIC
HOpe Center
1337 St. Andrews Avenue
North Vancouver BC V7L 0B8
PHQ-9
Over the last 2 weeks, how often have you been bothered by any of the
following problems?
Not at all
Several
days
More than
half the
days
Nearly
everyday
1 Little interest or pleasure in doing things
0 1 2 3
2 Feeling down, depressed, or hopeless
0 1 2 3
3 Trouble falling or staying asleep, or sleeping too much
0 1 2 3
4 Feeling tired or having little energy
0 1 2 3
5 Poor appetite or overeating
0 1 2 3
6 Feeling bad about yourself — or that you are a failure or have let
yourself or your family down
0 1 2 3
7 Trouble concentrating on things, such as reading the newspaper or
watching television
0 1 2 3
8 Moving or speaking so slowly that other people could have noticed?
Or the opposite — being so fidgety or restless that you have been
moving around a lot more than usual
0 1 2 3
9 Thoughts that you would be better off dead or of hurting yourself in
some way
0 1 2 3
PHQ-9 total score:
GAD-7
Over the last 2 weeks, how often have you been bothered by any of the
following problems?
Not at all
Several
days
More than
half the
days
Nearly
everyday
1 Feeling nervous, anxious or on edge
0 1 2 3
2 Not being able to stop or control worrying
0 1 2 3
3 Worrying too much about different things
0 1 2 3
4 Trouble relaxing
0 1 2 3
5 Being so restless that it is hard to sit still
0 1 2 3
6 Becoming easily annoyed or irritable
0 1 2 3
7 Feeling afraid as if something awful might happen
0 1 2 3
GAD-7 total score:
Q6
CORE10
I made plans to end my life in the last 2 weeks
NO YES
Patient name: Date:
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VCH ADULT ADHD REFERRAL FORM (Vancouver Coastal Health)

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Completed 13 October 2021

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