Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone Number *

Country

(###)

###

####

Preferred Method of Contact

Phone

Email

Text

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name

First Name

Last Name

Phone

(###)

###

####

2. Have you been formally diagnoses with any neurodivergent conditions? *

(e.g., ADHD, autism, dyslexia)

Yes

No

3. Are you currently working with any other support professionals? *

(e.g., therapists, occupational therapists, life coaches)

Yes

No

4. What are your primary goals for seeking support? *

Time management

Organization

Job readiness

Social skills

Stress management

Digital decluttering

Workplace accommodations

6. What challenges are you currently facing in achieving your goals?

Check all that apply.

Procastination

Overwhelm

Difficulty staying focused

Trouble prioritizing tasks

Managing stress or emotions

Communication difficulties

8. What is your current employment status?

Employed full-time

Employed part-time

Self-employed

Student

Unemployed

9. If employed, do you require support with workplace accommodations?

Yes

No

12. What type of sessions are you most interested in?

Check all that apply.

One-on-one coaching

Group workshops

Job readiness support

Mental health and stress management

Digital organization

15. How did you hear about Empowerment Solutions for Neurodivergent Adults?

Referral

Social Media

Website