If you have ADHD or think you might:
The A.D.D. Resource Center can help!

New client form

2022 New Client Information

"*" indicates required fields

I am filling this form out for:

Client Name*
Address (Please include APT, Suite, etc.)*
Date of Birth*
Marital Status
May we contact this person to discuss/release information
If that person calls ADDRC, may we share information about your progress?
Do you have children?

Choose from the drop down box
Please list your Doctor and/or therapist
Click the + at the end of the row to add more
Name
Phone
May we contact this professional?
 
List your current relevant medications with dosing
Click the + to the right of the row to add more lines
Medication
Doseage
Timing
 

COMMITMENT TO THE COACHING PROCESS:

This field is for validation purposes and should be left unchanged.
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