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ADHD Support Request

Please fill out the following form.

All information will be treated as confidential.

This service is currently only for 16+ plus and self referrals only for over 18's

First name*

Last name*

Date of birth*

Day

Month

Year

Address*

Email*

Phone*

Which Health Trust are you under?*

Northern Trust

Belfast trust

South Eastern Trust

Western Trust

Southern Trust

Please provide us with the name of your GP practice & address (this is for gathering service statistics)*

Do you have an ADHD Neurotype (diagnosed) or suspect you have an ADHD neurotype?*

Diagnosed

Undiagnosed

Suspect

Do you have any additional neurotypes? Eg Dyslexia, Dyscalulia, Dyspraxia, Tourettes, OCD ect

Yes

Other

Are there any particular area(s) of your ADHD you would like support with?*

Coping skills

Emotional Regulation

Overwhelm

RSD

Executive Dysfunction

Other

Can you tell us more about this?*

Tell us about how being neurodivergent impacts your day to day life

How can we best support you? eg education, peer support, skills workshops, counselling, advice ect

Please tell us how you heard about our service*

A member of our team will ring you to complete a referral form and an assessment will be required to ensure suitability for our service. We are running an extremely busy service and aim to get in touch with you as soon as possible.

Permission to contact

A Safe Space to be Me

info@asafespacetobeme.co.uk

028 9620 8284

Safeguarding Policy

Equal Opportunities Policy

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