Referring a Therapy Client for an ADHD or Autism Assessment: A Guide for Therapists
Last reviewed: 10/20/2026
Reviewed by: Dr. Kiesa Kelly
You have a client who is doing the work. They show up, they try the strategies, and they understand their patterns better than they did six months ago. Yet something keeps not fitting. If you have started to wonder whether to refer this client for an autism assessment or adult ADHD testing, the decision is usually less about how stuck therapy is and more about what kind of question you are now holding.
This guide is written for therapists, including counselors, social workers, marriage and family therapists, and psychologists who do not test. It covers when a therapy question has become a diagnostic one, and how to hand that question off without handing off the client. When you are ready to refer, our referral page for clinicians covers the practical steps.
In this article, you'll learn:
How to tell a diagnostic question from a therapeutic one
Which in-session patterns tend to point toward an assessment
How to raise an assessment with a client without pathologizing them
How an assessment-only referral works, so your client stays with you
What to send, what not to send, and what you get back
What to consider when your client lives outside Tennessee
The short version: Refer when the question has become "what is this?" rather than "how do we treat it?" At ScienceWorks, Dr. Kiesa Kelly completes every ADHD, autism and AuDHD assessment by secure telehealth. Your client keeps working with you, and with their written permission, we send you the results and recommendations.
The short answer: refer when the question is "what is this?", not "how do we treat it?"
Therapy is built to change how someone copes, relates and functions. An assessment is built to answer a different question: what explains this pattern, and what follows from that answer. Both are legitimate, and they often run side by side. The trouble starts when one is asked to do the other's job.
Three misconceptions tend to keep good referrals from happening.
Misconception 1: "If therapy is helping, an assessment isn't needed." Progress in therapy does not settle a diagnostic question. A client with undiagnosed ADHD or autism can gain real coping skills while still misreading why the same things stay hard. The assessment does not compete with that progress. It explains what the progress has been working around.
Misconception 2: "I already know it's autism (or ADHD), so a formal assessment adds nothing." Your clinical impression is valuable evidence, but co-occurring conditions are common and can look alike. Across ages, pooled estimates suggest roughly 28% of autistic people also have an ADHD diagnosis, 20% an anxiety disorder and 11% a depressive disorder, although those figures vary widely between studies [1]. A structured assessment is how those threads get separated, and how the conclusion holds up for a school, an employer or a prescriber. If anxiety is one of the threads you are tracking, the GAD-7 anxiety screener, a validated brief measure of generalized anxiety, gives you and your client a shared, repeatable reference point while the diagnostic question is sorted out [2].
Misconception 3: "Referring out means losing the client." An assessment-only referral sends one question out and keeps the relationship where it is. Your client comes to us for the evaluation and comes back to you with a report you can use.
🧭 Key takeaway: The trigger for a referral is the kind of question, not how long therapy has been going. When the work keeps returning to "what is this?", an assessment is the tool built for that question.
Signals in session that point to an assessment
There is no single sign that settles it. What you are looking for is a pattern you have watched over time, in the room, that keeps outlasting good work. In the UK, NICE suggests considering an autism assessment when persistent difficulties in social interaction or communication, or rigid and repetitive behaviors, occur alongside things like trouble sustaining work or relationships, previous or current contact with mental health services, or a history of another neurodevelopmental or mental health condition [3]. A client in therapy already has contact with mental health services, so the question is mainly whether you are seeing the first part, persistently.
The patient-facing version of this decision, written for your client rather than for you, is in our guide on whether to start with therapy or an assessment. What follows is the view from your chair.
Patterns that keep surviving good therapy
In our clinical experience, the most useful signal is a difficulty that stays the same shape even when everything around it improves. Your client understands their avoidance, has a plan and still cannot start the task. They learn emotion-regulation skills and still crash after every social event, regardless of how the event went. They report that the office lighting, the noise of a shared house or the texture of certain clothes take more out of them than the conversation itself.
Picture a client you have seen for a year for anxiety. The worry has eased. They use their skills, sleep better and describe themselves as calmer. Yet every week, the same three tasks are still unstarted, the same deadline still slipped, and the explanation is never fear of failure. It is closer to "I knew exactly what to do and could not make myself begin." You have tried breaking the tasks down, body doubling and values work. The anxiety treatment worked. The task-starting problem never responded, because it may never have been anxiety.
When a co-occurring picture makes the diagnosis unclear
In practice, anxiety, trauma, depression, sleep problems and burnout can each produce attention problems, social withdrawal and rigidity. That is exactly why they can hide ADHD or autism, and why they can also be mistaken for it. Adult ADHD is prone to misdiagnosis because its symptoms are subjective and overlap with many other conditions [4]. ADHD often persists from childhood into adulthood, and a European consensus statement describes it as underdiagnosed and undertreated in many European countries [5]. In a Dutch register of more than 1,200 autistic adults, about 1 in 4 said they had received at least one earlier psychiatric diagnosis they now considered a misdiagnosis, and among autistic women, almost 1 in 3 [6]. Those were self-reports from a highly educated sample, so they describe how often people feel misread, not a confirmed error rate. Still, they point at the gap a therapist is well placed to notice.
Camouflaging adds to the confusion. Some autistic adults, particularly women, describe camouflaging their social differences, which may take considerable effort, and in one small study, autistic women scored higher on a camouflaging measure than autistic men [7]. A systematic review found that higher self-reported camouflaging was associated with worse mental health, though it describes the findings as preliminary [8]. Masking is not unique to autism either. Adults with ADHD also report camouflaging, though less than autistic adults [9]. What you may see in session is a polished, articulate client whose exhaustion does not match how well the week appears to have gone.
When the client needs documentation for accommodations or a prescriber
Sometimes the question is practical. A client needs documentation for workplace or academic accommodations, or a prescriber has said they will consider ADHD medication only after a formal evaluation. In our experience, therapy notes rarely meet either need, while a psychological report that states the methods and diagnostic conclusions usually does. For ADHD medication, NICE, the UK guideline body, describes a full assessment before starting, including a review of coexisting mental health and neurodevelopmental conditions, alongside the prescriber's own physical health checks [10].
🔍 Key takeaway: The strongest signals come from what you have watched in the room over months, especially a difficulty that keeps its shape while everything else improves.
How to bring it up with a client without pathologizing
How you raise it shapes how your client hears it. In our clinical experience, the conversations that go well start from the client's own observations, not from a diagnostic label.
A few principles help:
Lead with the pattern. "We keep coming back to how hard it is to start things, even when the anxiety is low. I've wondered whether something else is contributing."
Offer the question, not the answer. "Would it help to know whether something like ADHD or autism is part of the picture?" works better than "I think you might be autistic."
Name what doesn't change. Therapy continues. The assessment is optional. A result of "neither" is useful too, because it rules something out.
Name what it could change. Accommodations at work or school, a clearer conversation with a prescriber, and a therapy plan that fits how your client's brain actually works.
Consider a client in her forties, seeing you for burnout, who mentions almost in passing that she has always rehearsed conversations in her head before having them. Later she says she cannot stand restaurants with background music. You might say, "You've mentioned a few things, like rehearsing conversations, sound bothering you more than most people and needing a full day to recover after a family visit, that sometimes go together. It might be worth finding out whether there's a common thread. What would it mean to you if there were?" That leaves the meaning in her hands. Some clients feel relief. Others need time. Either response is information.
If your client wants a brief self-check before deciding, the AQ-10 autism screener and the ASRS ADHD screener can start a conversation. The AQ-10 was developed as a brief "red flag" tool to help decide whether a full autism assessment is worth pursuing [11], and the ASRS is a short self-report screener for adult ADHD developed with the World Health Organization [12]. A screener is never a diagnosis. The UK's NICE guidance explicitly allows a comprehensive autism assessment when clinical judgment suggests autism, even without a positive screen [3].
🗣️ Key takeaway: Start from what your client has already noticed, offer the assessment as a question they can choose to explore, and say clearly that therapy with you continues either way.
Your client stays with you: how an assessment-only referral works
An assessment-only referral sends the diagnostic question out. It does not send the client out. Your client continues therapy with you while the assessment happens, and nothing about your treatment relationship has to change.
At ScienceWorks, the assessment is completed entirely by secure telehealth, and Dr. Kiesa Kelly completes every ADHD, autism and AuDHD assessment. We assess teens and adults ages 12 and up. If you or your client have questions about how well testing holds up over video, our review of the research on remote psychological testing covers which measures have been studied and where in-person testing is still the better call.
Under the APA Ethics Code, psychologists base diagnostic conclusions on information and techniques sufficient to support them [13]. In practice, that means the assessment is structured: interviews, standardized measures and developmental history, with the differential diagnoses considered on purpose rather than by default [3,4]. Your observations as the treating therapist can be part of that picture if your client agrees.
What to send, and what not to send
The most useful thing you can send is a clear referral question. "Struggles with focus" is much less helpful than "Is this ADHD, autism, both or neither, and is anxiety better explained by one of them?" Our patient-facing guide covers what a useful referral letter includes, so here we focus on what only you can add.
What a referring therapist can contribute that no one else can:
Treatment response. What you have tried, for how long, and what changed and what did not.
What has already been ruled in or out. For example, "Trauma processing reduced the nightmares but not the sensory overload."
What the result will be used for. Treatment planning, accommodations, a prescriber's decision, or all three.
What not to send:
No health information by email or web form. Once your client signs a release, we arrange a secure exchange.
No psychotherapy process notes. A focused summary is more useful, and it protects your client's privacy.
📋 Key takeaway: Send a specific question, your observations about treatment response and what the result will be used for. Never send health information until a release is signed and a secure channel is arranged.
What you get back, and how to use it in treatment planning
After the assessment, your client has a feedback session in which the results are explained to them. That reflects the APA Ethics Code expectation that psychologists take reasonable steps to make sure results are explained to the person assessed [13]. Your client receives a diagnostic letter and a written report, plus an accommodation letter when appropriate. With your client's written permission, we send you the results and recommendations.
How the report tends to change therapy, in our clinical experience:
A confirmed ADHD diagnosis often moves the work from insight to external structure: making time visible, cutting the number of steps between intention and action, and coordinating with a prescriber if your client chooses to explore medication. We do not prescribe, but we coordinate with prescribers and refer to one when it is needed.
A confirmed autism diagnosis often shifts goals from reducing "avoidance" to managing load: pacing social demands, sensory accommodations in daily life, and unmasking at a pace your client chooses. It can also change how you read past treatment that didn't work.
An AuDHD conclusion often explains why advice for one condition backfired. Novelty-seeking and a need for sameness can pull in opposite directions, and the plan has to hold both.
A "neither" conclusion is not a dead end. It usually points back at anxiety, trauma, sleep or mood as the main driver, now with more confidence, and the report often says what to prioritize.
Picture a client you referred for an autism assessment. The report confirms autism and notes significant sensory sensitivity and post-social recovery needs. Your treatment plan had treated the Sunday-evening shutdowns as depressive episodes. Reading the report, you both see a pattern of weekend social demands followed by predictable crashes. The next month of therapy is spent building recovery time into the week, and the "episodes" become less frequent. The report did not do the therapy. It changed what the therapy was aiming at.
🧩 Key takeaway: The report is a planning document for you as much as a diagnostic answer for your client. Read the recommendations, not just the conclusion.
Referring a client who lives outside Tennessee
Telehealth makes it easy to forget that, in general, licensure follows the client's physical location, not the clinician's. Whether a psychologist can assess a client in another state depends on where that client is during the sessions and on the psychologist's licensure and interstate authorization. Rules for assessment and therapy can also differ. Our guide to cross-state telehealth and PSYPACT explains how this works. Rather than working it out alone, ask us to confirm eligibility for a specific client before anything is booked.
Questions to ask any practice before you refer
Whether you refer to us or elsewhere, these questions help you judge whether an assessment will answer your question:
Scope: If both ADHD and autism are plausible, will one evaluation assess both, or will my client need a second referral?
Masking: How does the evaluation account for masking and lifelong compensation in adults?
Developmental history: What happens if my client has no childhood records or no parent available?
Differential diagnosis: How do you weigh anxiety, trauma, mood and sleep as alternative or co-occurring explanations?
Output: What will my client receive, and what can I receive with their permission?
A simple way to decide
If the problem is coping, relating or recovering, and the diagnosis would not change what you do next, keep going with therapy. If you keep seeing the same difficulty survive good work, or you cannot tell which of several conditions is driving what you see, refer for an assessment. A concrete documentation need is a separate, practical reason to refer. If you are unsure, the uncertainty is itself a reason to ask: a short conversation about the referral question costs little and usually settles it.
✅ Key takeaway: Keep treating when the question is "how." Refer when the question is "what," and send the question along with your observations.
Conclusion
The best referrals come from therapists who have watched a pattern closely enough to know therapy has done what it can with the current explanation. When you refer for an assessment, you are not stepping back from your client. You are getting them an answer that makes your work more precise. Your client stays with you, the question gets a structured answer, and the report comes back to the place where it will be used.
Your patient can book a free phone consultation (or text 931-223-1095) and mention you. No referral or prior authorization is needed. Please don't send health information by email or web form; once your patient signs a release, we arrange a secure exchange.
Frequently Asked Questions
Does my client have to stop therapy with me to get an assessment?
No. An assessment-only referral means your client keeps working with you and comes to us only for the evaluation. We complete the assessment, give your client feedback, and, with their written permission, share the results and recommendations with you. Therapy can continue during the assessment, and the report is written to be used in the work you are already doing together.
What will I receive after my client's assessment?
With your client's written permission, we send you the results and the recommendations. Your client has a feedback session in which the results are explained, and receives a diagnostic letter and a written report, plus an accommodation letter when appropriate. Without a signed release, we cannot share anything with you, even when you made the referral.
How do I bring up an ADHD or autism assessment with a therapy client?
Start from the pattern, not the label. Describe what you have both noticed, such as the same task-starting struggle surviving every strategy, and ask whether it would help to know if something like ADHD or autism is part of the picture. Make clear the assessment is optional, that therapy continues either way, and that a result of 'neither' is also useful information.
Can I refer a client who lives in another state for a telehealth assessment?
Sometimes. Whether a psychologist can assess someone by telehealth depends on where the client is physically located during the sessions and on the psychologist's licensure and interstate authorization, such as PSYPACT. Rules for assessment and therapy can also differ. Our guide to cross-state telehealth explains how this works, and our team can confirm eligibility for a specific client before anything is booked.
About the Author
Dr. Kiesa Kelly is a clinical psychologist and the founder of ScienceWorks Behavioral Healthcare. She earned her PhD in clinical psychology, with a concentration in neuropsychology, from Rosalind Franklin University of Medicine and Science, and completed practica, internship and an NIH-funded postdoctoral fellowship at the University of Chicago, the University of Wisconsin, the University of Florida and Vanderbilt University.
Trained as a neuropsychologist, Dr. Kelly has more than 20 years of experience with psychological assessment. She has sought out training in neurodiversity-affirming frameworks and modern assessments that capture ADHD and autism in previously undiagnosed adults, and she completes every ADHD, autism and AuDHD assessment at ScienceWorks.
References
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Disclaimer
This article is for informational and educational purposes only. It is not a substitute for professional clinical judgment and does not create a clinician-patient relationship with you or your client. ScienceWorks is not an emergency service. If your client is in crisis or at risk of harming themselves, call or text 988, or call 911 in an emergency.