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Regina M. Cashman, M.A., A.B.M.P.P., Phone (203) 595-9161, Email: regina@addcoach.info

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To request a free consultation of fifteen minutes, please complete and return the form below. Your email will be answered as soon as possible. Please check your email daily as unconfirmed free consult appointments are only held for 24 hours. After 24 hours, the appointment time is released to the next person requesting that time slot. Responses are usually sent within 24 to 48 hours. If you have not received a reply within 48 hours, please assume a technical error has occurred and resend your information.

Name *
E-mail Address *
Street Address *
Town & State *
Phone Number *
I am requesting services for: *
Occupation *
Place of Employment *
Marital Status: *
Number of children: *
Name & D.O.B. of child of concern. If the consult is for you, as an ADD Adult, please provide your name & D.O.B. *
If you are requesting services as a parent, please provide the name and birth date for your children other than the one for whom who are seeking services. *
If your child has not been diagnosed, but you are wondering if an evaluation, would be appropriate please share some of your concerns. *
Please list all OFFICIAL mental health diagnoses (ADD, Bipolar, OCD, etc.), and dates given, for the potential client. If you are seeking services for yourself, as a parent, please provide this information for the child of concern. *
Please list, and explain, any additional medical diagnoses not listed above. *
Please list all professionals who gave an official diagnosis (Name, Specialty, Town & Diagnosis given)) *
Does the potential client have diagnosed learning disabilities? If so, please specify. *
Please list all medication prescribed for the potential client; be sure to include name, dose, frequency & compliance. *
Please tell me a little about yourself and your family. *
How has the diagnosis of ADD affected the person diagnosed? *
How has the family been affected by ADD? *
Is there anyone living in the household who does not support the ADD diagnosis? If so, please explain. *
Is the ADD person presently working with a therapist? If so, for how long? *
What is the most important thing you would like me to know about you, or your child? *
Free consults are regularly scheduled for Monday and Thursday. Please choose your preferred day for your free consult. *
Preferred time of day for your consult? Please note, all times listed refer to Eastern Standard Time. *
Please tell me how you heard of my services. *
If you heard of my services via a professional, or friend, please specify. If you reached my site through a search engine please explain what keywords you used. If you checked other, please specify. *

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If you do not feel the need to work with a Coach on a regular basis, but would like to have a one time email consultation,  request a One Time Email Consult by clicking here.There is a $50.00 fee for this service, paid prior to service, via PayPal.

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