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Client Interest Form

Please complete the form below. After submission, a member of our team will be in touch as soon as possible with more information. Thanks!

Name(Required)

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Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Is it ok to text you?(Required)

Yes

No

Which coaching plan are you interested in?(Required)

For whom are you seeking service?(Required)

My Child

Myself

Both

Child's Name(Required)

First Last

Child's Date of Birth(Required)

Child's Cell Number (if applicable)

Child's Email Address (if applicable)

What age group is your child in?(Required)

Pre-Teen

Teen

College

Your Date of Birth(Required)

What age group are you?(Required)

College Student

Working Adult

Parent

Is there a diagnosis of ADHD?(Required)

Yes

No

What concerns do you have?

Check all that apply

Academic

Time management

Focus and prioritization

Working memory

Impulse control

Planning and organizing

Task initiation

Quality of work

Goal setting and motivation

Flexible thinking

Problem solving

Fluency of ideas

Managing emotions

Self-advocacy

Preparing for school/activities

Study skills

School applications

Career

Job search

Job/internship applications

Communicating on the job

Time management skills

Writing a resume

Interview skills

Managing job transportation

Work attire

Managing workplace expectations and systems

Goal setting for career

Career planning

Social

Finding friends

Maintaining friendships

Social / leisure activities

Lifestyle Management

Meal planning

Budgeting

Exercise and fitness

Work life balance

Home management

Personal hygiene

Emergency and safety skills

Accessing transportation

Knowledge of community resources

Organization of space

Passion Projects

Sleep cycles

Managing prescriptions

Nutrition intake

What do you think are the biggest challenges you or your family member are facing?(Required)

Do you or your family member have special needs such as:(Required)

Autism

Intellectual Disability

TBI

Other Health Impairment

Developmental Delay

Down Syndrome

Other

Not Applicable

Other special needs

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Serving community members from ages 9-99, our mission is to provide executive function coaching to individuals and families, through in-home, community-based or online support, training, and mentorship to empower independence and success with personal, academic, family, and life goals.

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Richmond, Virginia

Phone Number

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