Adult ADHD Contact Us Form “*” indicates required fields Thank you for taking the time to let us know any changes in your circumstances since you were initially referred for an ADHD assessment. Please confirm that you have already been referred for an ADHD assessment*This form is used for different teams and may be used by people who are not currently under our service. Yes No If you think you may have ADHD however have not already been referred we recommend you speak to your GP in the first instance. You can find additional information regarding ADHD here.Please be aware that these forms are not-monitored daily and are predominantly for updating our records. We may write to you in response to this form to advise of any changes made or recommendations. If your needs are of a clinical nature, or require a quicker response, we recommend you contact the relevant team by phone, they can be contacted via the phone numbers below : East Suffolk: 01473 279200 West Suffolk: 01284 733188 Norfolk and Waveney: 01603 974683 My detailsWhich adult ADHD team you have been referred to?* East Suffolk West Suffolk Norfolk and Waveney Name* First Last Date of Birth* Day Month Year RMY Number Optional OptionalIf known.NHS Number Optional OptionalIf known.Your Phone*Your Email* Enter Email Confirm Email If you would be interested in some information regarding NSFT Recovery College or NSFT Wellbeing services please tick this box and you will be sent some additional information/links Yes Optional Optional How can we help you?* I have moved to a new address I want to tell you about a change in my circumstances/details I have received a diagnosis from another provider I wish to be taken off the waiting list I want to tell you about something different or have more information to tell the team I have moved to a new addressAddress* Address Line 1 Address Line 2 Town/City County Post Code Have you registered with a new GP?* Yes No New GP Name*New GP Address* Address Line 1 Address Line 2 Town/City County Post Code Have you been referred to another ADHD service?* Yes No Name of New ADHD Service*Email Address of New ADHD Service Enter Email Optional Optional Confirm Email Optional Optional Phone Number of New ADHD Service Optional OptionalConsent to share information with new service?* Yes No I want to tell you about a change in my circumstances/detailsChange in circumstances or details* Physical health Mental health Contact details Other Please provide further detail* I have received a diagnosis from another providerProvider Name*Provider Address Address Line 1 Optional Optional Address Line 2 Optional Optional Town/City Optional Optional County Optional Optional Post Code Optional Optional Provider Phone Number Optional OptionalProvider Email Address Enter Email Optional Optional Confirm Email Optional Optional How was the diagnosis funded?* Right to choose Self funded If you have a copy of your diagnostic report, please upload a copy here Optional Optional Drop files here or Select files Accepted file types: pdf, docx, jpeg, jpg, Max. file size: 10 MB, Max. files: 1. I wish to be taken off the waiting listWould you like to be removed from the waiting list?* Yes No Why do you want to leave the waiting list?* I want to tell you about something different or have more information to tell the teamPlease provide details* Check your answers{all_fields}