New Client Info Form Please fill out this form so we’ll have all this out of the way before we see you. I am filling this form out for:MyselfClient Name* First Last Referred byAddress (Please include APT, Suite, etc.)* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email (Main)* Email (Secondary) Phone (Day)*Phone (Evening)Age*Date of Birth* MM DD YYYY Marital StatusSinglePartnerMarriedDivorcedName of Spouse, Partner or ParentDo you have children?YesNoPlease include sex and ages of childrenIf that person calls ADDRC, may we share information about your progress?YesNoYour Education Level CompletedChoose from the drop down boxLess than High SchoolGEDHigh SchoolSome CollegeCollege DegreeAdvanced DegreeYour OccupationYour Employer or SchoolAbout your doctor and/or therapistDoctor/Therapist 1 NameDoctor/Therapist 1 PhoneMay we contact Doctor/Therapist 1 to discuss your progress Yes No Doctor/Therapist 2 NameDoctor/Therapist 2 PhoneMay we contact Doctor/Therapist 2 to discuss your progress Yes No Current Diagnosis (If applicable)Current relevant medicationsMedication 1 including dosage/timingMedication 2 including dosage/timingMedication 3 including dosage/timingMedication 4 including dosage/timingMedication 5 including dosage/timingMedication 6 including dosage/timingI need more space for my medications Yes Additional medicationsAre there any issues we should know about, to help us do a better job of working with you?Please briefly list your major current concern(s): Why you’re here and what you’d like to gain.COMMITMENT TO THE COACHING PROCESS: I understand that successful Coaching requires a personal commitment of time, money and energy. I realize that to be effective, Coaching requires my honesty, openness and effort. I understand that the information provided by The ADD Resource Center and its Coaches is not medical, psychological, legal or financial, and must not be used in place of the consultation and advice of a physician, therapist or other healthcare provider, accountant, attorney, etc. I understand that Coaching is an adjunct to, and not a replacement for, appropriate medical or therapeutic interventions, and that Coaching is not intended to diagnose, treat, cure or prevent any problem or disability. I agree to pay the agreed upon fee per session, whether the session is in-person or by phone, and that payment is due at each session or by prepayment. I understand there is an additional fee when sessions are held at my office or home. If I cancel less than 36 hours prior to a scheduled session, I am obligated to pay for that session in full, unless a make-up session (in person or via phone) can be arranged within 3 days of the scheduled appointment. I agree that checks returned unpaid by the bank are subject to a $20 fee. I have read and agree to the Committment to the Coaching Process in the box above.* yes PhoneThis field is for validation purposes and should be left unchanged.