PRIVATE & CONFIDENTIAL

To ensure a smooth medical assessment, please complete all required fields and submit the screening forms as soon as possible. This form is mandatory, no later than 72 hours before your appointment
so your psychiatrist has time to review your clinical documents

You can partially fill out the form and SAVE your progress and revisit by saving the URL safely.
Once fully completed, please click SUBMIT.
The form will be securely stored in your patient record.

Questions or assistance: Telecare Coordinator ph 03-9034-9950.

Our assessments gather childhood history and current issues.
We'll gather collateral information from your parent/partner, questionnaires, and school reports.
You're encouraged to bring along your partner/spouse or parent to provide supporting collateral history.

PATIENT DETAILS

First Name *

Last Name *

Date of Birth *

Mobile Phone *

Sex assigned at birth *

Male FemaleOther

Preferred Pronoun

She/HerHe/HimThey/ThemOther

Knowing the cultural background can help us provide healthcare that meets your individual needs

None of theseAboriginalTorres Strait IslanderAboriginal and Torres Strait Islander

MEDICAL HISTORY

Has the patient seen a psychiatrist within the last twelve (12) months including in a hospital? *

NoYes

Estimate MONTH and name of doctor (or hospital) *

Has the patient been declined an ADHD diagnosis in the past? *

No (This is my first diagnosis)No (Previous diagnosis and request a review)Yes (I want a second opinion)

If a patient has received an ADHD diagnosis from a previous or current healthcare professional (e.g., pediatrician, psychiatrist, psychologist), we kindly ask for copies of relevant supporting documentation, such as reports or letters. Providing these documents will help expedite the assessment process.

Please be aware that Telecare practitioners will conduct an independent medical assessment regarding diagnosis and/or treatment plans. This assessment may differ from past evaluations.

Previous Report/letter with diagnosis

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Please indicate any disorders or conditions currently affecting the patient or diagnosed in the past.

ASD [Autism Spectrum Disorder]Substance use disorderPsychosisSuicide history

Other Relevant Medical Records

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e.g. childhood school teacher reports, psychologist or counsellor letter, social worker letter, paediatrician letter, pathology result (blood test within 3 months), radiology report, etc

Relevant Medical Records

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Relevant Medical Records

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NEXT OF KIN CONTACT DETAILS

Next of kin, carer, or 'support' person - Name *

Next Of Kin mobile *

Will this person assist the patient with appointments? *

YesNo - The patient will arrange appointments

Is your Next of Kin also your Emergency Contact? *

YesNo

Emergency Contact Person Name *

Mobile Phone

S8 Medication Prescription and Limitation

Please note that most of our psychiatrists primarily offer assessment and diagnostic services under Medicare item 291.

Following your appointment, our psychiatrists will provide a detailed report to your GP, which will include the assessment findings and a management plan for your ongoing care.

Please be aware that most of our psychiatrists do not provide prescriptions for medications. Instead, they will work closely with your GP, who will manage the prescribing of medications and ongoing monitoring, under an authority delegation.

If you are diagnosed with attention deficit hyperactivity disorder (ADHD), your psychiatrist may recommend medications such as Lisdexamfetamine (Vyvanse) or Methylphenidate (Ritalin). These are restricted drugs, and your GP can use the psychiatrist’s report to apply for a permit to prescribe the recommended medications. In many states, GPs are permitted to prescribe these medications with a letter from a psychiatrist and the necessary authorisation.

It is important to discuss this arrangement with your GP before your appointment with the psychiatrist.
Some GPs may be unable to prescribe these medications, unable to apply for authorisation, or have limited capacity for ongoing prescribing.

Yes, I agree *

Patient Consents

I understand that Telecare and Telecare specialists are unable to provide any emergency assistance for active suicidal and self-half and active psychosis presentations. If there is an emergency I will reach out to my GP or go to my nearest hospital or the local mental health service or the crisis team, or call 000 for emergency services *

I understand that in most cases, telehealth psychiatry is not suitable for the provision of ongoing care. Further appointment/s to discuss and/or adjust a treatment plan will be reviewed upon GP request.
Ongoing counselling and mental health support may be available with a psychologyist or psychotherapist (please speak with your GP if you are eligible for a care plan) *

I understand that if I may receive a lower Medicare rebate if I have seen a psychiatrist (privately or in the public sector), who has billed my appointment as a 291 psychiatric assessment, as per Medicare guidelines and limits *

ADHD assessment – what to expect?

Diagnostic assessment for ADHD and development of a tailored management plan requires several sessions/attendance.
For the first appointment bring a list of issues you believe need to be covered.
Assessments typically require collection of information from other sources about childhood developmental history and current difficulties. Collateral information will be collected through sources such as: interview of a parent and/or partner, parent and partner questionnaires and school reports.
Feel free to bring a family member, or a friend to provide supporting history.
You will be sent out few questionnaires that will need to be filled out and sent back before your scheduled appointment.
You can obtain school reports, if not saved, by calling schools.
NOTE WITHOUT HAVING ACCESS TO CHILDHOOD INFORMATION, THE DIAGNOSIS OF ADHD MAY REMAIN PROVISIONAL.
If a diagnosis of ADHD was made by a previous or current health professional (e.g. pediatrician, psychiatrist, psychologist etc.) you will be expected to obtain the supporting documentation (e.g. reports, letters). Provision of such documents will expedite the assessment process.
You would be asked to have blood tests, urine drug screens, physical health assessments, clearance from a cardiologist etc. before commencing treatment.
Please note if there are comorbid psychiatric or physical conditions, they may need to be stabilized before specific medicine for ADHD is commenced.

Yes, I agree *

I understand my assessment may require more than one (1) appointment for a comprehensive ADHD assessment, and additional consultation fees are applicable for each appointment. *

I understand that a diagnosis may be incomplete and/or treatment may be delayed if I have not submitted all the forms and questionnaires requested of me. I also understand that further appointment/s may be required upon completion and submission of these forms, and a fee for each appointment will apply *

DSM-IV criteria OR DIVA 2.0

Diagnostic form for ADHD in adults

This form is designed to help us understand your symptoms and experiences related to attention deficit hyperactivity disorder (ADHD). This form is confidential and will only be shared with clinicians only for matters relating to your care. Your responses will assist us in providing the best possible care and support tailored to your needs. There are 5 pages to complete and will take approximately 45 minutes of your time.

FORM 1 Part 1: Symptoms of attention-deficit (DSM-IV criterion A1)

Instructions: the symptoms in adulthood have to have been present for at least 6 months. The symptoms in childhood relate to the age of 5-12 years.
For a symptom to be ascribed to ADHD ( symptom present) it should have a chronic trait-like course and should not be episodic.

A1. Do you often fail to give close attention to detail, or do you make careless mistakes in your work or during other activities? And how was that during childhood? *

YesNo

Other:

Other

Symptom present *

YesNo

Symptom present *

YesNo

A2. Do you often find it difficult to sustain your attention on tasks? And how was that during childhood? *

YesNo

*Unless the subject is found to be really interesting (e.g.computer or hobby)

Other

Symptom present: *

YesNo

Symptom present *

YesNo

A3. Does it often seem as though you are not listening when you are spoken to directly? And how was thatduring childhood? *

YesNo

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

A4. Do you often fail to follow through on instructions and do you often fail to finish jobs or fail to meet obligationsat work? And how was that during childhood (when doing schoolwork as opposed to when at work)? *

YesNo

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

A5. Do you often find it difficult to organise tasks and activities? And how was that during childhood? *

YesNo

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

A6. Do you often avoid (or do you have an aversion to, or are you unwilling to do) tasks which require sustained mental effort? And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

A7. Do you often lose things that are needed for tasks or activities? And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

A8. Are you often easily distracted by external stimuli? And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

A9. Are you often forgetful during daily activities? And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

Supplement criterion A

Adulthood: Do you have more of these symptoms of attention deficit than other people, or do you experience these more frequently than other people of your age? *

YesNoNot applicable (patient is a child)

Childhood: Did you have more of these symptoms of attention deficit than other children of your age, or did you experience these more frequently than other children of your age? *

YesNo

Part 2: Symptoms of hyperactivity-impulsivity (DSM-IV criterion A2)

Instructions: the symptoms in adulthood have to have been present for at least 6 months. The symptoms in childhoodrelate to the age of 5-12 years. For a symptom to be ascribed to ADHD it should have a chronic trait-like course andshould not be episodic.

H/I 1. Do you often move your hands or feet in a restless manner, or do you often fidget in your chair?And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

H/I 2. Do you often stand up in situations where the expectation is that you should remain in your seat?And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

H/I 3. Do you often feel restless? And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

H/I 4. Do you often find it difficult to engage in leisure activities quietly? And how was that duringchildhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

H/I 5. Are you often on the go or do you often act as if “driven by a motor”? And how was that duringchildhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

H/I 6. Do you often talk excessively? And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

H/I 7. Do you often give the answer before questions have been completed? And how was that duringchildhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

H/I 8. Do you often find it difficult to await your turn? And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

Supplement criterion A

Adulthood: Do you have more of these symptoms of hyperactivity/impulsivity than other people, or do you experience these more frequently than other people?

YesNoNot applicable (patient is a child)

Childhood: Did you have more of these symptoms of hyperactivity/impulsivity than other children of your age, or did you experience these more frequently than other children of your age?

YesNo

Part 3: Impairment on account of the symptoms (DSM-IV criteria B, C and D)

Criterion B

Have you always had these symptoms of attention deficit and/or hyperactivity/impulsivity? *

Yes (a number of symptoms were present prior to the 7th year of age).No

If no is answered above, starting as from year of age.

Criterion C

In which areas do you have / have you had problems with these symptoms?

Adulthood

Childhood and adolescence

Other

Adulthood: Evidence of impairment in two or more areas? *

Yes NoNot applicable (patient is a child)

Childhood and adolescence: Evidence of impairment in two or more areas? *

Yes No

End of the interview. Please continue with the summary.

Potential details:

Form 2: Patient information Form (ADHD) with ASRS

ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

You can save your progress at any time and complete the form later. When you're finished, please click 'Next.'

If you have any questions or need assistance, please contact a Telecare Coordinator at (03) 9034 9950.

Your booking has been arranged with specialist psychiatrist, doctor: *

Score

Source: https://add.org

References:1. Schweitzer JB, et al. Med Clin North Am. 2001;85(3):10-11, 757-777.2. Barkley RA. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 2nd ed. 1998.3. Biederman J, et al. Am J Psychiatry.1993;150:1792-1798.4. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.Washington, DC, American Psychiatric Association. 2000: 85-93.

Self-Report of Current Symptoms

Telecare acknowledges that it shall not claim to possess any right, title or interest in and to the ADHD Self-report of current symptoms Assessment, and shall take no actions jeopardising the existence or enforceability of the proprietary rights which Telecare recognises as belonging to the authors of the following assessment, as well as any other alleged proprietary holders hitherto unknown.

Instructions:

Please select the most appropriate rating that best describes how you have felt and conducted yourself over the last few months

If you rate any questions as “often” or “very often” please give examples of relevant symptoms/behaviours in both childhood (before the age of 16) and adulthood.

Answer every question

Part 1: Inattention Symptoms

1. Do you fail to give close attention to details or make careless mistakes in schoolwork, at work, or with other activities? *

1a. If “often” or "very often” please give examples: (CHILDHOOD)

1b. If “often” or "very often” please give examples: (ADULTHOOD)

2a. If “often” or very “often” please give examples: (CHILDHOOD)

2b. If “often” or very “often” please give examples: (ADULTHOOD)

3a. If “often” or very “often” please give examples: (CHILDHOOD)

3b. If “often” or very “often” please give examples: (ADULTHOOD)

4. Do you find it difficult to follow through on instructions and fail to finish tasks because you get side-tracked or distracted? *

4a. If “often” or very “often” please give examples: (CHILDHOOD)

4b. If “often” or very “often” please give examples: (ADULTHOOD)

5a. If “often” or very “often” please give examples: (CHILDHOOD)

5b. If “often” or very “often” please give examples: (ADULTHOOD)

6. Do you avoid, dislike, or are relucatant to do tasks that require mental effort over a long period of time (such as schoolwork or homework)? *

6a. If “often” or very “often” please give examples: (CHILDHOOD)

6b. If “often” or very “often” please give examples: (ADULTHOOD)

7. Do you lose things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, glasses, mobile telephones)? *

7a. If “often” or very “often” please give examples: (CHILDHOOD)

7b. If “often” or very “often” please give examples: (ADULTHOOD)

8a. If “often” or very “often” please give examples: (CHILDHOOD)

8b. If “often” or very “often” please give examples: (ADULTHOOD)

9a. If “often” or very “often” please give examples: (CHILDHOOD)

9b. If “often” or very “often” please give examples: (ADULTHOOD)

Part 2: Hyperactivity and Impulsivity symptoms

2.1a. If “often” or very “often” please give examples: (CHILDHOOD)

2.1b. If “often” or very “often” please give examples: (ADULTHOOD)

2.2a. If “often” or very “often” please give examples: (CHILDHOOD)

2.2b. If “often” or very “often” please give examples: (ADULTHOOD)

2.3a. If “often” or very “often” please give examples: (CHILDHOOD)

2.3b. If “often” or very “often” please give examples: (ADULTHOOD)

2.4a. If “often” or very “often” please give examples: (CHILDHOOD)

2.4b. If “often” or very “often” please give examples: (ADULTHOOD)

2.5a. If “often” or very “often” please give examples: (CHILDHOOD)

2.5b. If “often” or very “often” please give examples: (ADULTHOOD)

2.6a. If “often” or very “often” please give examples: (CHILDHOOD)

2.6b. If “often” or very “often” please give examples: (ADULTHOOD)

2.7a. If “often” or very “often” please give examples: (CHILDHOOD)

2.7b. If “often” or very “often” please give examples: (ADULTHOOD)

2.8a. If “often” or very “often” please give examples: (CHILDHOOD)

2.8b. If “often” or very “often” please give examples: (ADULTHOOD)

2.9a. If “often” or very “often” please give examples: (CHILDHOOD)

2.9b. If “often” or very “often” please give examples: (ADULTHOOD)

Please select the area/s of your life which are most affected by your symptoms: (More than one (1) can be selected, or Select "NONE" if none apply) *

Summary of symptoms A and H/I (PATIENTS TO SKIP THIS PART)

Indicate which criteria were scored in parts 1 and 2 and add up

* Research has indicated that at adult age, four or more characteristics of attention problems and/or hyperactivity-impulsivity are sufficient forthe diagnosis of ADHD to be made. Kooij e.a., Internal and external validity of Attention-Deficit Hyperactivity Disorder in a population-basedsample of adults. Psychological Medicine 2005; 35(6):817-827. Barkley RA: Age dependent decline in ADHD: True recovery or statisticalillusion? The ADHD Report 1997; 5:1-5.** Indicate from whom the collateral information was taken.*** If the established sub-types differ in childhood and adulthood, the current adult sub-type prevails for the diagnosis.

ADHD Medication Waiver

This informed consent and waiver is provided to you in relation to the prescription of psychostimulant medications. You must acknowledge and agree to the following terms before such medications may be part of a treatment plan.

Where this Form refers to 'we', 'us', 'our' as Telecare Australia, and also includes our personnel, including all practitioners on our website or portal.

Where the Patient is a minor, or is otherwise unable to complete this Form, the Authorised Representative set out in the table above may sign this Form on behalf of the Patient and, in such cases, you will mean the Authorised Representative. You warrant and agree that, if you are completing and signing this Form on behalf of the Patient, that you have the required authority to do so.

This informed consent and waiver shall remain in effect for the duration of the Patient's treatment with the prescribed psychostimulant medication, unless revoked or amended in writing by the Patient or Authorised Representative.

Prescription of the Medication

If diagnosed with ADHD and medication is part of the patient's management plan:
You agree to follow your treating medical practitioner’s instructions regarding the proper use, dosage, frequency, and duration of the prescribed psychostimulant medication. You understand that failure to comply with these instructions may result in adverse effects or diminished therapeutic benefits.

You confirm that you have read and understood the information provided to you regarding the prescribed psychostimulant medication, including the potential risks, benefits, and side effects associated with their use.

You understand that you have the right to withdraw your consent for the treatment with psychostimulant medication at any time. To do so, you must provide written notice to your treating medical practitioner, and you agree to follow any instructions provided by them regarding the safe discontinuation of the medication. In the event of an emergency, where you cannot contact your treating medical practitioner, you agree to seek appropriate medical advice from your nearest open medical clinic or emergency room.

Use of Recreational Drugs

You confirm that the Patient is not currently using any recreational drugs. You acknowledge and agree that using recreational drugs while taking prescribed psychostimulant medications can lead to adverse health consequences.

You acknowledge that you have had the risks associated with taking psychostimulant medications explained to you, including the potential for abuse, dependence, and other side effects.

You acknowledge and agree that it is your responsibility to ensure you do not use any recreational drugs while taking the prescribed psychostimulant medication.

Liability

To the maximum extent permitted by law, we (and our personnel, including any medical practioners) will not be liable for any harm or injuries the Patient may suffer as a result of not following recommendations regarding the use of psychostimulant medication, unless we are negligent.

Emergency Services

You acknowledge and agree that we may call emergency services if (at our sole discretion) we have the reasonable opinion that the Patient is putting themselves or a third party at risk of harm.
Telecare is not an emergency service. In the event of an emergency where you are unable to contact your treating medical practitioner, you will seek appropriate medical advice from the nearest open medical clinic or emergency room.

I acknowledge and agree that I have read, understood, and agree to the terms outlined in this waiver.

Signed by the patient or Signed for and on behalf of the Patient by their Authorised Representative who warrant that they have the proper authority to do so

Next Step: Booking the telehealth appointment

Once you submit this form:

You will be taken to a BOOKING PAGE to select your preferred psychiatrist to book the next available appointment

The specialist and/or Telecare team may exercise discretion in accepting or declining the referral, with considerations based upon medical history and referral requirements. Our admin team may contact you to advise of any change to your appointment. Your understanding and cooperation are greatly appreciated.

If you have any questions, please call us on 03 9034 9950 for further discussion.

SIGNATURE

I have answered this form to the best of my knowledge and experience, and will update Telecare if I have made any error. I understand this information will be reviewed by my practitioner, and if I have any questions I understand I can contact Telecare ph 03-9052-4872 *

Patient Signature *

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Score form ---- OFFICE USE ONLY ----

Total number of criteria Attention Deficit

--/9

Total number of criteria Hyperactivity/Impulsivity

--/9

DSM-IVcriterion A

Is the number of A characteristics ≥ 6?

YesNo

Childhood

Adulthood

Is the number of H/I characteristics ≥ 6?

YesNo

Is the number of A characteristics ≥ 6?

YesNo

Is the number of H/I characteristics ≥ 6?

YesNo

DSM-IVcriterion B

Are there signs of a lifelong pattern of symptoms and limitations?

YesNo

DSM-IVcriterion C and D

The symptoms and the impairment are expressed in at least two domains of functioning

Adulthood

YesNo

Childhood

YesNo

The symptoms cannot be (better) explained by the presence of another psychiatric disorder

YesNo

If Yes, by

DSM-IVcriterion E

0 = none/little support

1 = some support

2 = clear support

Explaination

Diagnosis ADHD***

If Yes, subtype

314.01 Combined type314.00 Predominantly inattentive type314.01 Predominantly hyperactive-impulsive type