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Client Intake Form

Congratulations on taking this step! It is an absolute honor to partner with you and assist you in your journey towards your goals! This questionnaire is designed to aid both of us in getting the most out of our relationship. Please answer these questions as clearly and thoughtfully as possible. The “basic information” part is for invoicing and insurance purposes. If you do not have a clear or definitive answer to any of the following questions, that’s fine–just answer that you “wish to figure it out,” etc. Please complete the form before our first session.

BASIC INFORMATION

Name and Surname

Email

Country

ABOUT YOU

I consent to Divergent Empowerment collecting and storing this information about my ADHD diagnosis or traits and co-occurring conditions for the purpose of informing our coaching work together, as described in the Client Privacy Notice: https://www.divergentempowerment.com/privacy-notice. I understand I can withdraw this consent at any time and ask you to delete those records.

Do you have ADHD?

A
B
C

Do you have a co-occurring condition?

If so, which condition?

Do you have any sleep problems?

Do you have current previous problems with alcohol or drugs?

Do you take ADHD medications?

What is your attitude towards ADHD medications?

With whom do you live?