ADHD INTAKE FORM
Full Name
First Name
Last Name
E-mail
Phone Number
-
Area Code
Phone Number
1. Goal Setting
What are the biggest changes you would like to make to your life in the next 3 months?
What are the biggest changes you would like to see in the next 3 years?
What do you most want to achieve in your life/career
What will have to happen in order to achieve this?
What have been your 3 greatest achievements to date?
2. Expectations
What do you expect to achieve as a result of hiring me as your coach?
Do you have a personal or professional vision?
What is your definition of success?
What would you like to give to people?
What would you like to contribute to the world?
3. History
What is the hardest thing you have ever had to overcome?
Have you had any major transitions/events in the past 2 years?
Have you ever worked with a coach /therapist teacher? What worked/didn't work for you about those relationships
4. Tolerations
Name 5 tolerations - things you are putting up with. eg: cranky friends, a broken care, a cluttered home, etc
In a typical week what do you spend your time doing?
What is your favorite part of the day and why?
What is your least favorite part of the day?
What are your main stressors?
On a scale of 1-10, 10 being high, how stressed are you in your life right now?
1
2
3
4
5
6
7
8
9
10
Low
High
1 is Low, 10 is High
5. Areas of Life
What areas of your life would you like to see improvement? (Check all that apply)
career/professional
family/hobbies/ creative
financial
friends/relationships
home/living space
personal growth/ learning
play/leisure/fun
self care/health
service/personal character
6. Coaching You
hat can I tell you when you are stuck that will help you move forward?
How do you wish to be held accountable to stay on track for your goals/field work?
What's the plan B if that fails?
7. ADHD Stuff
How do you treat /cope with your ADHD?
What are the areas of your ADHD that you find the most debilitating?
Have you tried medications? If “yes” which ones?
Do you have any co-morbid conditions? If “yes”, please specify
Do you see any specialists?
8. Hobbies
What are your hobbies?
What do you currently do with your leisure time?
8. Supporting You
What are the coaching techniques that best support your way of working? (Please check all that apply)
Brainstorming strategies together
Accountability, checking on goals field work
Support encouragement, validation
Finding and removing obstacles
Painting a vision for your future
Insight into who you are and your potential
Suggesting or designing action steps
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