Coaching Intake Form - Adult

Welcome! Let’s Build a Space That Works for You.

Traditional systems often ask you to change who you are. Here, we change the system, not the person. This form is a tool to help us understand your unique wiring, sensory needs, and what "thriving" actually looks like to you.

ADHD Coaching Intensives are for coaching and education only. This is not therapy or medical treatment.

Before we begin, all clients must sign a coaching disclosure and informed consent form. If we find that you need therapeutic support,

I’m happy to discuss referrals to licensed professionals.

Low-Demand Guidelines:

Respect Your Energy: Skip any question that feels like a "spoon-drain" right now. We can chat about it later.

No Masking Required: Be as honest as you need. There is zero judgment here.

Your Pace: Take as long as you need. Your brain is welcome exactly as it is.

Fill out what you can, and let's start working with your brain, not against it.

1. Identity & Communication

First and Last Name

Birthday

Month

Day

Year

Phone

Pronouns

Address

Diagnosis/Neurotype: (e.g., ADHD, Autistic, AuDHD, Dyspraxic, etc. Self-identification is fully honored here.)

Communication Style: Do you have a preference for text vs. talk?

2. Health & Clinical Support

Current Medications: (List any meds you are comfortable sharing, especially those affecting focus, sleep, or mood.)

Anxiety Profile: How does anxiety show up for you? (e.g., Physical tension, "spinning" thoughts, avoidance/procrastination, or social anxiety.)

3. Executive Functioning & Friction Points

The "Wall of Awful": What tasks currently feel impossible to start?

Working Memory: Do you struggle more with following verbal instructions or remembering where you put physical items?

Time Perception: Do you lean more toward "Time Blindness" (losing track) or "Time Anxiety" (waiting hours for an appointment)?

4. Social Dynamics & Safety

Social Battery: What drains you the fastest? (e.g., Small talk, bright environments, large groups, or unclear expectations.)

Rejection Sensitivity: Does the fear of "getting it wrong" or being criticized stop you from trying new things?

Advocacy: How comfortable do you feel asking for accommodations in your daily life?

5. Sensory & Regulation

Sensory Overload: What are your "non-negotiable" sensory triggers? (e.g., specific sounds, fluorescent lights, textures.)

Regulation Tools: What currently helps you "reset"? (e.g., Stimming, quiet time, special interests, movement.)

6. Coaching Goals

Top Priority: If we could lower the "volume" on one anxiety or executive function struggle this month, what would it be?

You can use this space to share anything else you would like me to know:

A Note on Clinical Information

Disclaimer: Coaching vs. Therapy

This service is coaching, not medical treatment or therapy. We focus on strategies, goals, and support. I cannot diagnose or treat mental health disorders.

I understand this is a coaching partnership and does not replace professional medical or mental health care.

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Welcome! Let’s Build a Space That Works for You.

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