Preliminary Adult Intake Form

Please Note: An Intake Appointment can only be scheduled for those who have already been diagnosed with ADD/ADHD, and are currently, or have in the past, received treatment.

Before completing the form below, please read about my Fees for Service and My Payment Policy.

Please fill out the following form to the best of your ability.  Do not be concerned if you do not remember everything; do the best you can. If the question does not apply, enter N/A in the response window.

* Required fields
Name *
E-mail Address *
Date of Birth *
Sex *
Marital Status *
List all household members, their age, and their relationship to you.. *
Street Address *
Town or City *
State *
Zip Code *
Home Phone Number *
Mobile Phone Number *
Do you have the ability to send and receive text messages? *
Do you have the ability to video chat? *
If you have the ability to video chat, what is your I.D.? *
Please provide your height and weight. *
Place of Employment *
Position Held *
Please provide a brief summary of your concerns. *
What are your hopes and expectations for the coaching process? *
List which of the following professionals you have seen, in an attempt to seek help for your concerns. *
Please list all mental health diagnoses you have received, by whom, and date. (month & year) *
Please provide a time line of all medications tried for all mental health diagnoses. To the best of your ability, give dose (mg.) & frequency. If you never tried medication, enter N/A. *
* Please select your preferred appointment time option. Please note, all times listed refer to EST. *
Please provide a second choice for your appointment time. *
I have read the Fees for Services and Payment Policy *

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