Please note the referral form will not be accepted without the following: 
•	All sections of the referral form must be completed
•	Child/Young Person must have a Solihull based GP
•	School information for Child/Young Person must be provided

Child or young person being referred	
Surname of Child/Young Person:	First Name(s):	
Date of Birth:	NHS No:	
Address: 

Postcode:	
Male 			Female 	
Details of Parent/Carer	
Parent/Carer’s Name(s):					Relationship to child	:

Parental Responsibility:  Mother   Yes  No           Father   Yes    No 

Address (if different from above):

Daytime Contact Number/ Mobile(please ensure this is up to date):

Email:	
Details of any diagnosis/medication/surgeries etc from birth – to date	

	
Details of School	Details of G.P.	
Name of School:

Telephone number: 	Name and Practice Address:	
Child Protection Details (if any)		
Child Protection Plan  	Yes   No   Unknown 
Is the child in the care of the Local Authority: 	Yes   No   Type of care order………………………	
Consent/Information Sharing	
It is important to ensure that the parent/carer is aware that information detailed in referrals made to Children and Families Division Services may be shared with other health professional and external agencies such as Education and Social Care.
Has the person with legal responsibility consented to this referral and sharing of information?
Yes  Please tick box if consent has been gained. If consent has not been obtained this referral cannot be accepted.	
Referrer Details	
Referred by: 	
(please print name)	Signed:	
Designation or Relationship to Child:
	
Referrer’s full contact address, postcode, telephone: 

IMPORTANT: Is the child currently being seen by:	
Professional	Name	Contact Tel No	Base	
Social Worker 	
			
Medical Consultant	
			
Others, e.g. Specialist Assessment Service, SOLAR, SALT, Physiotherapy, OT, Dietetics, Educational Psychology, SISS, SEMH etc.	

			

ADHD NURSE LED SERVICE – (Attention Deficit Hyperactivity Disorder)

Early developmental history/school 	
Any concerns at school? Please note we only accept referrals for school aged children.
Yes  No           

What age were concerns noted:

	

Reason For Referral	
Current situation, please describe what is happening and when, frequency, duration – giving examples of incidents or events which are having an impact on physical health, education (school), self esteem, emotional well being, relationships.	

	
Other influences impacting on the current difficulties.  Please describe or enclose relevant correspondence	

	

Ethnicity Category	
Ethnicity:
Home Language	Is an Interpreter required? Yes   No 

Will carers have any difficulties reading appointment letters              Yes   No   Don’t Know 	

Please send completed referrals via email to: soladhd.nursingteam@uhb.nhs.uk
(Preferred option)
 
OR

Via Post to: 

ADHD Clinical Nurse Specialist/Team Lead
Community Paediatrics
Friars Gate, 3rd Floor
1011 Stratford Road
Solihull
B90 4BN

Referral form revised September 2024

	
Date Sent (By School) - 

ADHD Nurse Team and 
Community Paediatrics

Date Received (By Team) - 

Friars Gate, 3rd Floor
1011 Stratford Road
Solihull
B90 4BN

 ADHD Office: 0121 746 4453
Paediatrics Office:  0121 746 4455
Soladhd.nursingteam@uhb.nhs.uk
communitypaediatricians@uhb.nhs.uk

	ADHD Referral - Primary Education Document.

Thank you for referring this child to our service for an ADHD assessment. If you could please take the time to complete this document, the information you provide will help us with our assessment of the child. The child’s parents should have given you consent for the referral and enable the service to collect the information from you.

All teachers and parents must complete a SNAP-IV Questionnaire.	
Child’s Name:	                                                                                                               	                                                                
Date of Birth:			                     		Age:		Years		Months               
NHS Number:         		                                     Gender:   	    Male/Female
Name of School:    ___________________________________________________________
Year/Grade:		                                                                                                            	   
Person completing the form:
SIGNATURE		
PRINT NAME		
ROLE/DESIGNATION		
CONTACT TEL / EXT		
ADDRESS	
	
DATE COMPLETED 		
PLEASE CAN YOU PROVIDE US WITH AN UP TO DATE TIMETABLE / LESSON PLAN FOR SCHOOL OBSERVATION PURPOSES 	
1.	What are the main difficulties (if any) as you see them?

2.	In comparison with his/her peers how is the child at present in terms of:
	Well Below Average	Below Average	Average	Above Average	Well Above Average	
General level of ability						
General level of attainment						
Ability in reading						
Ability in writing
Ability in maths						
Ability in spelling						

Additional comments – (e.g. does the child’s chronological age differ significantly to their learning age?, are there any diagnosed or suspected learning disabilities?)

3.	Is the child receiving any extra help and if so, what strategies are in place?

   

4.	Are any services already involved with the pupil? (Please provide name of worker if known)
SISS 		
SEMH		
Behaviour Support		
Education Psychology (EPS)		
Speech and Language Therapy		
Communication and Autism Team (CAT)		
Paediatrician		
School Nurse		
SAS		
Other (please state)

5.	Do any of the following apply to the pupil? (Please tick and add review date if appropriate)
Universal Provision	

	
Targeted Provision	

	
Specialist Provision	

	
Other (Please state)	

	
*Please provide us with a copy of any recent paperwork related to the above where possible.

6.	Compared with his/her peers, how would you rate the child in terms of the level of the following?

	Major Problem	Medium Problem	Minor Problem	No Problem	
Butting into others’ conversations					
Leaving seat without permission					
Difficulty turn taking					
Forgetfulness					
Inability to listen to instructions					
Blurting answers out of turn					
Fidgeting or squirming					
Excessive and inappropriate running					
Inability to complete task					
Poor organisation					
Careless errors in work					
Excessively noisy in play					
Excessive and inappropriate talking					
Easily distracted					
Inability to sustain attention					
Dislike of tasks requiring concentration					
Losing things necessary for certain tasks eg books					
Excessive motor activity	

7.	How would you rate the following?
	Well below average	Below average	Average	Above average	Well above average	
Self esteem/confidence						
Response to rules & discipline						
Attendance record (in %)						

8.	Personality – Please circle the adjectives which you think best apply to this child:

happy		content 	likeable 	lively 	noisy 	self-confident 	adaptable quiet 	shy 	sad 	popular 	caring 	anxious 	fearful 	sensitive immature 	fussy 	attention-seeking 	withdrawn 	aggressive 	mature     compliant disobedient 	hyperactive 	tidy 	careless 	perfectionist
In addition, please tell us how you would describe the child’s personality:

9.	Relationship with Peers – Please comment on how the child relates to other children ie, ability to work and play cooperatively, ability to make and maintain friendships, problems with bullying.

10.	Relationship with Adults – Please comment on how the child relates to adults, ie 
cooperativeness, seeking help, response to discipline and encouragement.

11.	 General behaviour – Structured (lesson) time.

12.	General behaviour – Unstructured (Break) time.

13.	 Additional comments/concerns: In your opinion, how does this child’s general behaviour and emotional development compare with the normal range for his/her age?

PLEASE CAN PARENTS/CARERS AND ALL TEACHERS FILL OUT THE ATTACHED SNAP-IV 26 FORM AND RECORD OUTCOMES BELOW – 

Please use the hyperlink or QR code below to do so.

SNAP-IV 26 - Teacher & Parent Rating Scale | QxMD 

Once you have completed the questionnaire please copy and paste your answers onto the end of this document. Please make sure to clearly identify who has filled out the questionnaire.

Name: 	                                 Relationship to child:    

Name: 	                                 Relationship to child:    

Name: 	                                 Relationship to child:    

Name: 	                                 Relationship to child: