Parental Request

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Parent / Guardian:

minlen1Please insert your parent / guardian
Address:

minlen1Please insert your address
Email:
Please indicate which Trust you belong to (if you are unsure, contact your local Doctors Surgery):

Belfast: Northern:

South Eastern: Southern:

Western:
Telephone/Mobile:

minlen1Please insert your telephone number
Name of Person Referred:

minlen1Please insert the name of the person referred
Date of Birth:

minlen1Please insert the Date of Birth of the person referred
Date of Diagnosis:

minlen1Please insert the Date of Diagnosis for the referree
Medication Type:

minlen1Please insert your medication type
Please give details of other members of your family:

Name School/Employment Date of Birth
Reason for Referral:

500 characters remaining

minlen1Please insert the reason for this referral
Family History:

500 characters remaining

minlen1Please insert your family history
Have there been any major events which have occurred within the family?:

500 characters remaining
Please detail input from other Professionals / Agencies to avoid duplication of services:

500 characters remaining
Please give us more information about your child with a diagnosis of AD/HD:

500 characters remaining
Has this referral been discussed with the young person?:

Yes: No:
What is the young person’s view of referral?

500 characters remaining
What do you hope to achieve through this referral to the ADD-NI Support Centre?

500 characters remaining
Please indicate the service you require below:

(Please note: due to high demand for services, programme places are limited.)

Therapeutic Group Work
A 6-week programme for a maximum of 6 young people per group

7 - 9 years		10 - 12 years
13 - 15 years		16 - 18 years

Counselling for Adolescants (13 - 18 years)
Art Therapy (5 - 18 years)
Sibling Group (5 week programme)

Name of sibling:

Age:

Name of Emergency Contact:

minlen1Please insert the name of the emergency contact
Address:

minlen1Please insert the address of the emergency contact
Telephone/Mobile:

minlen1Please insert the telephone number of the emergency contact
If your require any further information please feel free to contact us. You can find all of our contact information on this page.

Apply for Services

Belfast:		Northern:
South Eastern:		Southern:
Western:

Name	School/Employment	Date of Birth