Welcome to our online booking form for your Connors Screening Request

Prior to carrying out an ADHD Screening of your child, we would appreciate the completion of this form so that we are able to administer the screening in the most effective manner.

Please note - if you leave the form without completing and submitting it, you'll need to start again. Once submitted our team will receive an automated email with a password protected PDF file, containing the information you provide.

Children being booked for this service must be 6 years or over. If your child is younger or nearing the age of 6, please contact our team to check at [email protected]

As part of our security policy regarding personal data, everything submitted is automatically erased from our website after 24 hours.

If you're ready to begin, please click 'Next' below.

Diagnosis Status

Has your child seen a paediatrician?*

Yes

No

What was the opinion provided?*

Has your child been referred to CAMHS?*

Yes

No

What has been offered/done?*

(e.g. ADOS)

Has your child received any diagnosis already?*

Yes

No

Who gave the diagnosis?*

What was the diagnosis given?*

School

School Contact Information

Please provide name of one contact at your child’s school, who knows them well:

First Last

Please tell us what their role/relationship is to your child at school*

(e.g. SENDCo/Teacher)

School Contact email*

Enter Email Confirm Email

Please provide a direct / personal contact email address for this contact where possible

School's Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

School Contact number*

Alternative Contacts

As your child isn’t attending school, we must speak to a or multiple third-party contact(s) who know(s) your child well.

Please provide up to three names with valid email addresses in order of contact preference. (Should the first contact not respond, we will endeavour to contact the second, and so on).

How many contacts do you have?*

1

2

3

Contact 1 - Name*

First Last

Contact 1 - Email*

Enter Email Confirm Email

Contact 2 - Name*

First Last

Contact 2 - Email*

Enter Email Confirm Email

Contact 3 - Name*

First Last

Contact 3 - Email*

Enter Email Confirm Email

Parent/Legal Guardian's information

Parent/Legal Guardian's name*

First Last

Parent/Legal Guardian Contact Email*

Enter Email Confirm Email

Parent/Legal Guardian's Address*

Please ensure that the address you provide matches your billing details for the card used for payment.

Street Address Address Line 2 City County Post code Country

Contact number*

Payment

Connors ADHD Screening Request (6-18yrs)

Price:

An initial screening service, should you want to see if a formal assessment is appropriate. This involves the parent and third party contact(s) completing a comprehensive ADHD initial screen. The ADHD screening tool we use helps us to see if ADHD may be present.

Total

Conners 4 ADHD Screening Request

Information about your child

Diagnosis Status

School

School Contact Information

Alternative Contacts

Parent/Legal Guardian's information

Payment