PRE-SCREENING FORM FOR ADULTS

We are here to help anchor you with 1:1 coaching services.

This form is for adults who want ADHD Coaching for themselves. If you are a parent of a student in need of coaching, please go back and complete the "ADHD/EF Coaching for Students & Parents" on the Contact Us page.

If you are interested in adult ADHD coaching and would like to set up a pre-screening call, you are in the right place! The first step is to complete this brief confidential pre-screening form. This helps us understand your needs and to be sure that coaching is the right fit for your situation; it should take about 5 minutes to complete.

*Required responses. Please write N/A if not applicable.

First Name of person completing form: *

Last Name of person completing form: *

Email *

Phone *

Full Name of person in need of coaching (or write ‘self’): *

What is your relationship to this person (or write ‘self’): *

How did you hear about us? *

Briefly explain why you are reaching out for coaching (1-3 sentences). What are the specific struggles you are experiencing? *

Have you been diagnosed with ADHD? (A diagnosis is not necessary for coaching.) *

Do you have any other mental health diagnoses or learning disorders? *

Are you currently taking any medication for ADHD or any other mental health diagnoses? *

Are you currently in therapy or have you previously received therapy? *

Have you had coaching before? Was it helpful or not helpful? *

Are you interested in: *

Where are you located?

City *

State *

Country *

Click here if you would like to be added to our contact list for: *

I understand that 1:1 coaching rates vary by coach and will range from $500 to $720 per month. I am also aware that coaching is not covered by insurance (although Life Anchored Coaching can provide documentation for reimbursement if your HSA/FSA covers ADHD/EF Coaching). *

Is there anything else that would be helpful for us to know? *

After pressing submit, you will find in your inbox a short 5-minute introductory video and next steps, should you decide to move forward with a pre-screening call.

Watching the video is a prerequisite to our call. Please check your spam folder if you don't receive an email in the next 5 minutes or contact [email protected] and let us know.

Thank you!

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