ADHD Informant and Collateral History Form

This form will assist in the ADHD assessment of your family member, friend or spouse. Depending on how long you have known the person being assessed for ADHD, you will be asked about your observations of them in childhood and/or adulthood. Please allow 10-15 minutes to complete this form. 

Please note the information you provide can only be accessed by your psychiatrist. It is stored securely according to Australian privacy legislation and all data is encrypted. If you would prefer to have a paper form to be mailed out to you instead, please contact Pax Centre reception on (08) 9455 5440

Patient Details

Informant's details

Please provide your details below. You will then be asked to provide the details of the person being assessed for ADHD. 

  • If you selected "since they were a child" please skip the "DIVA-5 Adult questions" - to do to this you will just have to select "No, none of the examples were applicable" in each row. 

  • If you selected "since they were an adult" please skip the "DIVA-5 Childhood questions" - to do to this you will just have to select "No, none of the examples were applicable" in each row. 

Office Use Only


DIVA-5 Childhood Questions

Childhood - Inattention Symptoms

For each question, please consider whether the person being assessed had these symptomsbetween the age of 5yrs and 12yrs. Please provide examples if you can think of any, as this supports the answer


Childhood - Hyperactive & Impulsive Symptoms

For each question, please consider whether the person being assessed had these symptoms between the age of 5yrs and 12yrs. Please provide examples if you can think of any, as this supports the answer.


DIVA-5: Adulthood Questions

The following questions assess the person's symptoms as an adult. Please consider their symptomsfor the last SIX MONTHSwhen responding to each question. 

Adulthood: Inattention Symptoms


Adulthood: Hyperactive / Impulsive Symptoms

The following questions assess the person's symptoms as an adult. Please consider their symptomsfor the last SIX MONTHS when responding to each question. 


Additional Comments


Submit Form

I declare that the above information is an honest account of the symptoms I have observed in the person being assessed for ADHD.

Draw signature|Type signatureClear