Request Initial Consultation

Request Free Phone Consultation
No Obligation for Future Services Required

Please complete the form below to schedule a Free Consult Video appointment.

Free Consults are 15 minute to 30 minute video appointments, via Zoom.

The Free Video Consult provides the opportunity for you to assess my style and

services to see if ADDCoach Services is a good fit for your needs, without spending

any money, or making a commitment. Likewise, the consult allows me to assess whether

or not ADD Coach Services is the best option for you, at this time.

If I think my services are not appropriate for you I will make a recommendation as to

what services may be more appropriate.

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Your request for a Free Video Consult will be answered as soon as possible.

Please check your email daily as unconfirmed free consult appointments are only held for

24 hours.

After 24 hours, the appointment time is released to the next person requesting that time

slot.

Responses are usually sent within 24 to 48 hours.

If you do not receive a reply within 48 hours, please assume a technical

error has occurred and resend your information.

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PLEASE NOTE:

Phone calls, inquiring about my services, or requesting a first time appointment,

are not returned.

Return phone calls are reserved for existing clients and professionals on my

clients' treatment teams. There are not enough hours in a day for me to return all

of the additional phone calls received.

The return of the completed Free Consult Form, ensures time is set aside, within my

schedule, for us to speak.

A Free Consult appointment does not obligate you to commit to ADD Coach Services.

It simply gives us both the opportunity to assess if my services are right for your situation.

Please fill out the following form to the best of your ability. If the question does not apply, enter N/A in the response window.

* Required fields
Name *
E-mail Address *
Street Address *
Town & State *
Zip Code *
Home Phone Number *
Cell Phone: *
Do you have the ability to video chat via Zoom? *
Please provide your Zoom I.D. *
Occupation *
Place of Employment *
Partner's Occupation: *
Partner's Place of Employment *
Marital Status: *
Number of children: *
If the consult is for you, as an Adult with ADHD, please provide your name & D.O.B. *
If you are requesting services as a parent, please provide the name and birth date for your children. Otherwise enter N/A. *
Please share your main concerns regarding the potential client. *
Please list all OFFICIAL mental health diagnoses, and dates given, for the potential client. *
Please list, and explain, any additional medical diagnoses not listed above. *
Please list all professionals who gave an official diagnosis (Name, Specialty, Town & Diagnosis given)) *
Does the potential client have diagnosed learning disabilities? If so, please specify. *
Please list all medications prescribed for the potential client; be sure to include name, dose, frequency & compliance. *
Please tell me a little about yourself and your family. *
How has the diagnosis of ADHD affected the person diagnosed? *
How has the family been affected by ADHD? *
Is there anyone living in the household who does not support the ADHD diagnosis? If so, please explain. *
Is the potential client presently working with a therapist? If so, for how long? *
What is the most important thing you would like me to know about you, or your child? *
Free consults are 15 - 20 minutes. Please select your preferred time. While I can not guarantee your day and time preferences will be available, every effort is made to take them into consideration when scheduling your appointment. *
Please select a second choice for your appointment day. *
Please tell me how you heard of my services. *
I have read and agree to the Privacy Policy *

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CONTACT INFO: EMAIL: addcoach1@yahoo.com PHONE: 203.595.9161

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