Pre-Assessment Questionnaire

1

Name* This field is required.(of client requesting assessment)

First Name

Last Name

2

Are you 17 years of age or older?* This field is required.(of client requesting assessment)

YESNO

3

Due to the nature of virtual care, we are currently only offering assessments to individuals aged 17+.

You can discuss a referral with your primary care provider or self refer to a clinical psychologist. Here are some options for a psychological assessment:

In London: Dr. Lindsay Forbes and Associates, London Psychoeducational Assessment Centre

In Toronto: Northerm Elm Assessment and Treatment, The Redpath Centre

In Guelph or Ottawa: ADHD/Spectrum Centre

elsewhere in the province: check out CADDAC's resource list.

We apologize that we're not able to provide you with this service at this time.

4

Email* This field is required.please add adhd@bpcounselling.com and info@bpcounselling.com to your email "safe list" to prevent our emails about your assessment from being filtered into your junk mail.

example@example.com

5

Phone Number

Please enter a valid phone number.

6

Have you previously received a diagnosis of ADHD/ADD?* This field is required.

YESNO

7

Do you recall having symptoms of ADHD in childhood (before the age of 12)?* This field is required.(Please note this is required in order to proceed with an Assessment)

YESNO

8

Are you currently receiving care from any of the below mental health professionals? Or have recently been referred to one?* This field is required.Choose all that apply

Psychotherapist

Social Worker

None

Other

9

Are you currently involved with a Psychiatrist or Psychologist?* This field is required.Including a recent referral to one?

YESNO

10

In order to ensure you recieve the best possible care we cannot offer you an ADHD assessment while you are also working with an external psychiatrist or psychologist.

You can discuss your ADHD concerns with your psychiatrist or psychologist and if they feel you would benefit we can receive a referral from them directly.

We apologize that we're not able to provide you with this service at this time.

11

Are you currently experiencing thoughts of suicide or self harm?* This field is required.

YESNO

12

We're sorry to hear you're struggling, but so glad you're here. Once you complete this form our assessment coordinator will be in touch to book a Mental Health Assessment. She can also set you up with one of counsellors for support until your assessment is booked. We're here for you.

In the meantime:

You can contact Reach Out for 24/7 support: 1-866-933-2023

Or if you are in immediate danger please go to your nearest emergency department for support.

13

Have you been diagnosed with bipolar disorder or schizophrenia?* This field is required.

YESNO

14

Thank you for sharing this information with us! If you have been diagnosed with bipolar or schizophrenia you will need a psychiatrist referral. We can provide this through a Mental Health Assessment, but will not be able to conduct an ADHD assessment. If you have a Primary Care Provider they can also make this referral for you.

15

Have you been diagnosed with oppositional defiant disorder or conduct disorder?* This field is required.

YESNO

16

Have you been diagnosed with a developmental disorders or disability?* This field is required.Including Autism or Asperger's

YESNO

17

Thank you for sharing this information with us! Depending on the diagnosis, you may require a referral to a psychiatrist or a psychogological assessment done externally. We can provide these referrals through a Mental Health Assessment, but will not be able to conduct an ADHD assessment . If you have a Primary Care Provider they can also make this referral for you.

18

Have you been diagnosed with fetal alcohol syndrome or fetal drug exposure?* This field is required.

YESNO

19

Thank you for sharing this information with us! If you have been diagnosed with FASD or FDE you will need a psychiatrist referral. We can provide this through a Mental Health Assessment, but will not be able to conduct an ADHD assessment. If you have a Primary Care Provider they can also make this referral for you.

20

In the past five years, have you been hospitalized related to your mental health, including addiction?* This field is required.

YESNO

21

In the past year, have you had any unexplained episodes of fainting or passing out?* This field is required.

YESNO

22

Thank you for sharing this information with us! You are still eligible for an ADHD assessment however you will need Cardiac clearance prior to starting any stimulant therapy. If you have a Primary Care Provider they can coordinate this referral for you. If you do not have a Family Doctor you can also attend a walk-in clinic for the cardiac referral.

23

In the past two years, have you had any seizures?* This field is required.

YESNO

24

Thank you for sharing this information with us! If you have a history of epilepsy or seizures you will need a psychiatrist referral. We can provide this through a Mental Health Assessment, but will not be able to conduct an ADHD assessment. If you have a Primary Care Provider they can also make this referral for you.

25

Do you have any known tics?* This field is required.

YESNO

26

Thank you for sharing this information with us! If you have a history of Tics we would need clearance from a neurologist before any type of stimulant therapy can be initiated. While Tics can be associated with ADHD, you may still meet the criteria however a referral to psychiatry may also be needed.

27

Have you previously suffered a traumatic brain injury or had concussions that required multiple medical visits? Or have you had a serious head injury or concussion in the past year?* This field is required.

YESNO

28

Thank you for sharing this information with us! Depending on the diagnosis, you may require a referral to a psychiatrist or a psychogological assessment done externally. We can provide these referrals through a Mental Health Assessment, but will not be able to conduct an ADHD assessment until clearance from these services has been given. If you have a Primary Care Provider they can also make this referral for you.

29

Do you have heart disease?* This field is required.This wouldn't include high blood pressure you're currently being treated for.

YESNO

30

Do you have untreated or inadequately treated low red blood cells (anemia), low B12, or low blood iron levels (ferritin)?* This field is required.If so, please bring any recent blood work to your assessment.

YESNO

31

Thank you for sharing this information with us! You are still eligible for an ADHD assessment however you will need to have these symptoms managed prior to completing an ADHD assessment and starting stimulant therapy. If you have a Primary Care Provider they can coordinate this for you. If you do not have a Family Doctor you can also attend a walk-in clinic for assistance.

32

Have you been diagnosed with glaucoma or high pressure in your eyes?* This field is required.

YESNO

33

Have you needed medical attention for disordered eating, overexercise, or the use of laxatives?* This field is required.

YESNO

34

Thank you for sharing this information with us! If you have a history of an eating disorder you will need a psychiatric assessment. We can provide this through a Mental Health Assessment, but will not be able to conduct an ADHD assessment. If you have a Primary Care Provider they can also make this referral for you.

35

Have you gotten in trouble with law enforcement because of your road rage, or been charged with traffic violations that prevented you from getting motor vehicle insurance?* This field is required.

YESNO

36

Have you ever been violent towards people or animals or had legal issues related to your violence or aggression?* This field is required.

YESNO

37

Thank you for sharing this information with us! Unfortunately we are unable to conduct an ADHD assessment for you. We recommend you reach out to your Primary Care Provider or a walk-in clinic for a referral for psychiatric assessment. We appreciate your understanding and wish you all the best!

38

Assessment & Diagnosis Agreement* This field is required.Based on the answers you've provided, its possible that your Nurse Practitioner may have to refer you to another provider to initiate your treatment. We can still assist you with an assessment and diagnosis if you meet the criteria and we will facilitate the referral to another provider if needed. Given this information, would you like to proceed with an assessment?

YESNO

39

Do you have Private Insurance? It would be best to check with your provider prior to booking an ADHD assessment to ensure they will cover our services. Our ADHD assessments are conducted by Nurse Practitioner's. Our services are unfortunately not covered by OHIP.

40

In order to ensure you recieve an accurate diagnosis and the best possible care you would benefit from an assessment by a psychologist or psychiatrist.

You can discuss a referral to a psychiatrist with your primary care provider or self refer to a clinical psychologist. Here are some options for a psychological assessment:

In London: Dr. Lindsay Forbes and Associates

In Toronto: Northerm Elm Assessment and Treatment

In Guelph or Ottawa: ADHD/Spectrum Centre

elsewhere in the province: check out CADDAC's resource list.

We apologize that we're not able to provide you with this service at this time.

41

Please upload any documentation you have relating to your previous diagnosis of ADHD (optional).You may be eligible for a lower cost treatment intake with our nurse practitioner if you have a recent assessment (< 5 years) and can provide us with a copy of a comprehensive report. After completing this questionnaire please contact our assessment coordinator for more info at adhd@bpcounselling.com.

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