ADHD Coaching Intake | Counselling Center

First name

Last name

Email

Do you consent to your counsellor communicating with you through email? (Eg. sending you resources, worksheets, appointment reminders, etc.).

Yes

No

Address

Birthday

Year

Month

Day

Phone

Can we leave a voicemail at this number?

Yes

No

Gender (M/F/O)

Allergies

Emergency contact

Emergency Contact Phone Number

Emergency contact address

Family Physcian

Marital Status (married, single, widowed, common law, divorced, remarried)

Please list immediate family members (eg, partner, ex-partner, step-parent, # of children and their ages, step-children and their ages.

Of the family members listed above, who do you currently live with?

In a few sentences please explain why you are seeking out ADHD coaching Services?

How long has this problem been going on for? What have you already tried in attempt to cope with these struggles.

Have you seen a counsellor in the past? If so, what was helpful about your past experience? Was anything unhelpful?

What are your current ADHD Coaching Goals? (Focus of coaching is to support with implementation of ADHD friendly methods and strategies in the identified areas).

Do you currently have any unmet needs (stable/safe housing, food insecurity, insufficient finances, transportation barriers)?

How is your appetite (has there been a recent increase or decrease in appetite or weight)?

How many hours of sleep do you get per night (average)? Do you feel rested upon waking?

Do you struggle to fall asleep?

Do you have frequent waking throughout the night?

How would you describe your energy level throughout the day?

Do you have any physical conditions that are connected to the reason you are seeking service? If so, please explain the physical condition, how it impacts the presenting problem, and current treatments (e.g. thyroid disorder, chronic illness etc.).

Are you currently employed? Is the presenting problem getting in the way of your ability to obtain or maintain employment?

Do you currently use substances? These can include but are not limited to: caffeine, nicotine, alcohol, marijuana, hallucinogens, stimulants, and depressants. Is your use problematic?

Do you have any cultural or spiritual practices or beliefs? Do you want these practices/beliefs to be integrated into your counselling services? Please explain.

Is there anything else I should know about you, or that you would like to share with me?

​ADHD Coaching Intake Form

ADHD Coaching Intake Form