Free Professional Consult - Adult

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Thank you for taking the time to fill out our questionnaire. Your answers will give our professional staff an opportunity to assess your particular needs. Be certain that upon completion of the questionnaire schedule a convenient time for your one on one consultation. This will give us time to further customize a plan that's right for you.

All of the information you share will be kept private and will only be used for the purpose of the consultation.

First Name(*)

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Phone(*)

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Country(*)

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Last Name(*)

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Email(*)

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State / Province(*)

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Age(*)

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Gender(*)

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Describe the challenges you experience in the following areas.

(Feel free to share as much or as little information as you feel comfortable with)

Home

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Work

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Behavior

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Academic performance

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Overall performance

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Which of the following behaviors do you struggle with?(*)

Trouble concentrating and staying focused Tendency to overlook detailsHyper focusedDisorganization and forgetfulnessImpulsive behaviorEmotional difficultiesHyperactivity or restlessness e.g. getting bored easily, talking excessively, doing a million things at once and racing thoughts. Please make a selection(s)

Have you considered other solutions?

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Did you take action on any of these?(*)

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Were you satisfied with the results/outcome?(*)

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Additional information

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Please add your mobile number if you would like to receive updates via text

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