Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

How did you hear about Russell Coaching LLC? *

Google Search

CHADD Listing

ADDitude Listing

Referral

Other

Current Psychiatric Diagnoses

Check all that apply.

ADHD/ADD

Anxiety

Depression

Asperger’s/Autism

Sensory Issues

Do you have a diagnosed learning disability in any of the following domains?

Check all that apply.

Learning Disability in Reading, including Dyslexia

Learning Disability in Writing, including Dysgraphia

Learning Disability in Math, including dyscalculia

Slow Processing Speed

Poor Working Memory

Do you have a formal written plan in place at school?

Yes

No

If YES, what kind of plan?

Public School 504

Public School IEP

Private School Student Support Plan

What are your areas of Executive Functioning Weakness?

Check all that apply.

Impulse Control

Working Memory

Emotional Control

Sustained Attention

Task Initiation

Planning & Prioritizing

Organization (of supplies, belongings, etc.)

Time Management

Goal-Directed Persistence (finishing non-preferred tasks)

Flexibility

Do you currently see a therapist?

Yes

No

Do you currently see a medical professional for medications related to ADHD, Anxiety, or Depression?

Yes

No