Name
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First Name
Last Name
Email
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Age
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Level of Education
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Elementary School
High School
Post-secondary (ie., University, College, etc.)
Graduate Studies
Professional Studies (ie., Medical School, Optometry School, Pharmacy School etc.)
Please choose one of the following:
I have clinically diagnosed ADHD/ADD.
I do not have diagnosed ADHD/ADD but I am on route to receiving a diagnosis.
I do not have diagnosed ADHD/ADD but I suspect that I do.
I do not have ADHD/ADD but I still want to improve my focus and productivity skills.
I am a life coaching client.
Are you currently taking any medications related to your ADHD/ADD or focus?
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Yes
No
N/A
Do you have any medical or mental health conditions that we should know about to ensure your safety and well-being during coaching?
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Please provide me with a detailed description of the issues you are facing:
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On a scale of 1-5 (strongly disagree to strongly agree) please rate yourself on the following issues:
Please note that although this part is optional (for time purposes), feel free to submit your answers as this will give me an in depth look into your needs.
Focus and Productivity Buzzword Glossary:
Hyperactivity - activity where one may experience increased movement, impulsive actions, a shorter attention span, and easily being distracted
Impulsive - act of doing something without much thought of the consequences
Procrastination - act of delaying something
I struggle with making decisions (small and/or big)
I make impulsive decisions often
I struggle with maintaining focus on daily tasks
I struggle with maintaining focus on tasks required for work, school, business etc.
If I am not fully enjoying something then I have a hard time focusing
I have trouble focusing and listening when someone is speaking to me
I can only focus for a short amount of time
I fail to keep track of time
I struggle how long it takes to complete something
I often isolate myself from spending time with friends and family because it is too much work
I don't make appointments because its too much work
I often miss appointments that are important
I often forget things or have difficulty remembering them
I get really excited about ideas but cannot to making them happen
I get overwhelmed in busy environments
My personal space is often disorganized and cluttered
I frequently feel restless or hyperactive
I feel tired and fatigued most days
I often struggle with motivation
I deal with procrastination often and have trouble starting tasks
When I start one task, I get distracted by another
I feel like my days are disorganized
I struggle with confidence and low self-esteem
I struggle to ask for help with things
I often judge myself for my inability to focus and complete tasks
I experience happiness only when I am focused on a task I enjoy doing
I struggle with maintaining a daily routine
Please provide me with a short description of your expected outcomes with coaching:
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On a scale of 1-5 (strongly disagree to strongly agree) please rate yourself on the following goals:
Please note that although this part is optional (for time purposes), feel free to submit your answers as this will give me an in depth look into your needs.
I want to improve my focus
I want to stay more organized
I want to improve my decision making skills
I want to be able to make my appointments and other basic commitments
I want to feel less restless and hyperactive
I want to experience more energy throughout my day
I want to build a better relationship with managing my time
I want tasks to seem less overwhelming
I want to learn how to sustain motivation
I want to overcome my self-limiting beliefs
I want to achieve greater productivity for my daily life, school, career, and/or business
I want to learn practical skills that will help me be successful in my daily tasks, school, career and/or business
I want to learn about focus and productivity tools
I want to learn more about the benefits of on focus and productivity
I want to enhance my communication skills
I want to improve my listening skills
I want to learn how to manage my emotions
On a scale of 1 to 10, how committed are you to making positive changes in your life? (1 = Not committed, 10 = Highly committed)
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Are you willing to complete assignments or tasks outside of coaching sessions to work towards your goals?
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Yes
No
What motivated you to seek coaching at this time?
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Are there any past experiences or traumas that may impact our coaching sessions?
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What is your preferred coaching frequency and duration?
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Have you ever worked with a life coach or therapist before? If yes, please provide details.
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How did you find me?
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Instagram
LinkedIn
Kijiji
Facebook
Tiktok
Google Search
Referred from a friend or family member
Any additional comments or questions?
