Lamplight API response

Parent/Carer Details

Name of Parent/Carer at above address

Does this parent have parental responsibility?

Does this parent have shared parental responsibility?

If there is shared parental responsibility, please provide their name, address, contact number and email address below.

Name of Parent/Carer at above address

Alt Address

Postcode (Alt address)

Email (Alt Address)

Mobile (Alt address)

Child's Details

DOB

If the child is under the age of 6 they can only be screened once they are aged 6 or older. If you have any questions, please contact a member of the team

NHS Number

Find your NHS number: Copy and paste the following link into another browser window- https://www.nhs.uk/nhs-services/online-services/find-nhs-number/

Demographics

Gender

Is gender the same as that assigned at birth?

Gender assigned at birth

The QbTest is a medical device which follows strict guidance. To ensure the results are accurate the gender inputted into the technology must be the same as what they were assigned at birth. If you have any questions, please contact a member of our team.

Sexual Orientation -Which of the following options best describes how you think of yourself?

Nationality

Ethnicity

Religion

Child/Young persons over 16

Child/young persons contact number

Child young persons email address

Emergency contact

Emergency contact name

Emergency contact number

GP Details

Registered GP Practice

Does the child/young person have an assigned paediatrician? If yes, please provide their name, organisation and telephone number

Accessibility

Do you have any accessibility requirements (including hearing, large print documents or wheelchair access)

If you have accessibility requirements please detail here

Do you require an interpreter?

Unfortunately, we are unable to provide interpreters for the appointment. Should one be required then you would need to source this yourself.

Full medical history

Have you been diagnosed with any conditions?

Please ensure you include ALL disabilities, ill health, or medical conditions, including if you need to wear glasses when using a laptop.

Details of all conditions diagnosed

What conditions are currently being explored?

Have you undergone assessments for any other conditions? E.g. Dyslexia. If yes, please provide details

Details of assessments for other conditions

Have you been screened for sensory processing disorder?

Outcome of screening for sensory processing disorder

Have you been assessed for any language disorders e.g. receptive language disorder?

Outcome of screening for language disorders

Does the client have Cystic Fibrosis?

Does the person bringing the client to the appointment have Cystic Fibrosis?

Has the child/young person been diagnosed with any developmental delays? If yes, please provide details

Details of developmental delays

Has the child/young person been meeting their developmental milestones? If no, please provide details.

Details of developmental milestones

Current medication (please list all medication including dosage)

Any history of brain injury or brain illness?

If 'Yes' please state when the brain injury occurred and the severity

Do you have a history of fainting?

Do you have a history of heart disease?

Is there a family history of heart disease?

Do you have a history of high blood pressure?

Is there a history of sudden and unexpected death in the family?

Are you aware of any genetic conditions? Such as Raynaud’s syndrome

Do you have high cholesterol?

Do you have a history of liver disease?

Do you have a thyroid condition?

Do you have any allergies? If yes, please specify below

Details of allergies

Is there a history of epilepsy in the family?

If you answered yes, please provide details on who and the relation to the client.

Support

Do you have a history of suicidal ideation or self-harm?

If yes, please provide details and report any support you have accessed

Have you experienced any traumatic experiences which may have resulted in post traumatic stress disorder?

Details of traumatic experiences

Please select if there is a family history of the following

ADHD

Autism

Dyslexia

Epilepsy

Sensory processing disorder

Tourette’s or tics

Do you smoke?

Do you have any concerns about alcohol or substance misuse?

If yes, please provide full details including what drugs and the frequency of use. Please also report any interventions or support accessed in relation to drug and alcohol use.

Please note, 14 units or more a week is considered heavy drinking. If you have any concerns about the client’s alcohol consumption, visit drink aware for more advice https://www.drinkaware.co.uk/

The QbTest is a cognitive assessment, no elicit substances or alcohol can be in the client’s system on the day of the test and up to 72 hours prior to the test, otherwise the results will be invalid. This includes the use of marijuana

Please provide any additional significant/relevant information which you feel may be beneficial to the appointment

Any other agencies involved (e.g. CAMHS, social services etc.)?

Details of other agencies involved

Is there any police involvement or risk of police involvement? If yes, please detail

Brief details of Police involvement/risk

Education Information

Education status

School/college name

School/college address

Class teacher name

Class teacher (Telephone number)

Does the child/young person have Special Educational Needs?

SENCO name

SENCO (Telephone number)

Has the child/young person ever been excluded? If yes, please provide details

Yes No

Details of child/young persons expulsions

Child's Current attendance rate %

Please provide details of any activities the child/young person takes part in inside or outside of school?

Why do you think the child/young person has ADHD?

What are the barriers to learning for this child as you see them?

Important policies

• I confirm that all information provided is truthful and accurate and understand that if I have withheld anything that this will affect my child/young person’s assessment outcome and could impact their ability to obtain a formal diagnosis.

• In some cases, no outcome may be provided, and the appointment may be aborted or cancelled. The appointment would be non-refundable

• I understand that the cost of the assessment is non-refundable (including if you do not attend, cancel, or change your mind about accessing the assessment).

• It is your responsibility to ensure nothing will impact the validity of the QbTest, such as hunger, injury, alcohol consumption, elicit substances, exhaustion, or stimulants such as caffeine.

• If your child requires glasses you must ensure these are brought to the appointment.

• This is a cognitive test. At the appointment your clinical advisor will assess if anything may impact the validity of the results, such as being hungover. In some cases, this may result in the test not being possible and we will have to re-book.

• If the test was not possible due to the factors outlined in these policies, then you will be subject to the £225 re-booking fee.

• If we discover after the QbTest is completed that factors may have impacted the validity of the test, then the test results will be invalid. You may then need to re-book the QbTest and pay the £225 re-booking fee.

Re-booking the appointment?

If you contact to re-book the appointment 5 working days before your appointment is due there is no additional charge.

If you contact to re-book the appointment less than 5 working days before your appointment is due then there is a £225 re-booking charge.

If you do not attend your appointment and then call to re-book, there is a £225 charge for the new appointment.

Late to the appointment?

If you are more than 15 minutes late we will not have time to complete the appointment and the appointment would need to be re-booked. The re-booked appointment would be subject to the £225 re-booking fee.

Further information

• I understand that all referrals are subject to review before they can be accepted.

• The ADHD Foundation hold the right to not accept referrals if they do not meet the criteria.

• The ADHD Foundation is not a Psychiatric service and so holds the right to reject referrals where more specialist care is required.

• The QbTest is a type 1A medical device, which follows strict governance on whom can use the technology.

• The ADHD Foundation have a zero-tolerance policy on abuse towards staff.

• By submitting this referral form you understand that being abusive towards staff will result in your referral to our services being terminated. The cost of the assessment would be non-refundable.

• You consent to the ADHD Foundation Neurodiversity Charity recording, processing, and sharing your information.

• Please note: This is not related to marketing - it enables us to process and accept this referral (i.e. adding names and contact details to our waiting list. As well as emailing you the results report/outcome of the assessment).

Do you consent to the ADHD Foundation contacting you to take part in research? Please note, if you say no this will not impact your ADHD assessment.

CCTV in operation

1. Purpose of CCTV - The primary purpose of the CCTV cameras in the QbTest room is to ensure the safety and security of all participants, staff, and property, and to maintain the integrity of the ADHD assessment process.

2. Data Protection and Privacy - Compliance with Laws: All recordings and data captured by the CCTV cameras will be managed in accordance with the Data Protection Act 2018 and the General Data Protection Regulation (GDPR).

Data Storage: Recorded footage will be securely stored for a period of 28 days, after which it will be automatically deleted unless required for legal or compliance reasons.

Access to Data: Access to recorded footage is strictly limited to authorised personnel only.

3. Use of CCTV Footage - Assessment Integrity: Footage may be reviewed to ensure the integrity and proper conduct of ADHD assessments. Safety and Security: Footage may be used to investigate any incidents or safety concerns within the test room.

Training and Quality Assurance: Footage may be used for staff training and quality assurance purposes to improve service delivery.

4. Notification and Consent - By entering the test room, participants and staff acknowledge and consent to the recording and monitoring by CCTV cameras for the purposes outlined above.

5. Confidentiality - All recorded footage will be treated as confidential and handled with the utmost care to protect the privacy of individuals.

Only authorised personnel will have access to the footage, and it will not be disclosed without proper authorisation or legal requirement.

6. Security Measures - Secure Storage: All recorded footage will be stored in a secure environment with appropriate access controls.

Technical Safeguards: Measures will be in place to prevent unauthorised access, alteration, or destruction of recorded footage.

7. Participants Rights - Access to Footage: Participants have the right to request access to footage in which they appear, subject to applicable data protection laws.

8. Policy Review - These terms and conditions will be reviewed regularly to ensure they remain compliant with relevant laws and best practices. Updates will be communicated to all relevant parties.

9. Contact Information - For any questions or concerns regarding the CCTV and the use of recorded footage, please contact:

Tom Howcroft, Data Protection Officer, ADHD Foundation, 3rd Floor, 54 St James Street, Liverpool L1 0AB, Telephone: 0151 541 9020 or DPO@adhdfoundation.org.uk

Do you consent to CCTV being in operation during your child's assesssment. Please note, we cannot accept your referral unless you consent to this.

Type of appointment

• If you are accessing the full assessment, prior to the appointment ADHD rating scales will be sent. It is your responsibility to contact the school and get them to complete the school rating scales.

• Please note, we cannot refer to Dr Nawaz without school rating scales. All rating scales MUST be returned before the results report can be completed.

• If you are accessing the QbTest only, you understand that we cannot refer you to our associate Paediatrician unless your child has completed the full assessment.

• If you decide after the QbTest that you wish to be referred to our associate Paediatrician you would have to pay £225 so that you can complete the other aspects of the full assessment.

Neurodiversity Clinic - Child Referral

Other information