Full Name *

Phone *

Email *

Who is this application for? *

Adult (yourself)

Parent seeking support

Teen (13–17)

Child (7–12)

Time Zone *

Have you (or your child) been officially diagnosed with ADHD? *

Yes, formal diagnosis

Not yet, but very likely

Not sure

Prefer not to say

If yes, what type? *

ADHD — Combined

ADHD — Inattentive

ADHD — Hyperactive

Not sure

Are you currently receiving any other ADHD support? *(Check all that apply.)

Describe any other support you are currently receiving. *

Describe the something else. *

What made you apply for 1-on-1 coaching today? *

What are your top 3 goals for coaching? *

(Example: better focus, calmer mornings, less yelling, more confidence, better grades, improved emotional control.)

Describe anything else that has been holding you back that is not listed above. *

How committed are you to making real changes? *

10/10 — Let’s go

8–9 — Very committed

6–7 — Somewhat committed

Below 6 — Still figuring things out

What session schedule works best? *

Weekdays (morning)

Weekdays (afternoon)

Weekdays (evening)

Weekends (limited availability)

Do you prefer virtual or in person? *

Virtual

In Person

Either Works

Are you ready to invest in private coaching? *

Yes, I’m ready

I need to talk to someone first

Not sure yet

(Private coaching ranges: $347–$497 per month depending on age group.)

How long do you want coaching support? *

3 months

6 months

12 months

Not sure yet

Is there anything else you want me to know before I review your application? *

Privacy Policy | Terms of Service