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Back
A Dad's Guide
Member Resources
Home
ABOUT US
About Dr. Norrine Russell
Our Team
FAQs
Career Opportunities
SERVICES
Start Here
Connected Coaching for Students
Basics of EF for Elementary Students
Life Launch Coaching for Young Adults 18-30
School Choice Scholarship
Summer Enrichment Programs
Spring Survival Program
Client Release of Information
BOOKING DR. RUSSELL
RESOURCES
Podcasts
Dr. Russell's Book
Russell Coaching Blog for Parents
Professional Affiliations
Tips & Suggestions
Symptom Tracker
CONNECTED COACHING PORTAL
SCHEDULE A COMPLIMENTARY CALL WITH DR. RUSSELL
A DAD'S GUIDE: PARENTING SONS WITH ADHD
A Dad's Guide
Member Resources
Russell Coaching
CONNECT
Name
*
First Name
Last Name
Age
Date of Birth
MM
DD
YYYY
School
Grade
How did you hear about Russell Coaching LLC?
*
Google Search
CHADD Listing
ADDitude Listing
Referral
Other
If you checked other, please describe:
If you were referred by someone, please provide their name:
If you were referred by a school or a professional, please provide the name of the organization:
Please type the city and state of the person or organization that referred you:
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
Any current significant medical concerns?
Goals for Coaching? This can be as short or as long as you like.
Name of Person Responsible for Payment
Email of Person Responsible for Payment
Phone Number of Person Responsible for Payment
Do we have your permission to speak to your parent(s) about you?
*
YES
NO
Name of Parent 1
Phone of Parent 1
Email of Parent 1
Name of Parent 2
Phone of Parent 2
Email of Parent 2
Thank you!
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