Client Information Form

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Phone

This field is for validation purposes and should be left unchanged.

Welcome to your intake form. This form collects essential information - your background, clinical diagnoses, current care by other professionals, coaching goals, emergency contacts and a brief wellbeing assessment (CORE-10) - so I can tailor our sessions, monitor your progress and ensure your safety in line with ICF standards. All information will be handled securely and used only to support your journey.

Name*

First Last

Name you would like me to use (if different from above)

Optional. If you go by a different name from the one above, tell me here.

Pronouns (optional)

Optional, to help me address you correctly.

If other, please share your pronouns (optional)

Optional

Title (optional)

Optional. If you use a title such as Dr, Ms, etc

If other, please specify (optional)

How should I address you in sessions? (optional)

For example: Linda, Ms Smith, Dr Patel, first name only, or “use my surname”.

Date of Birth*

Day

Month

Year

Email*

Mobile Phone*

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Employment Status*

What industry or field do you work in?

Job title or role (optional)

If you’d like to include work in our coaching, what would you like support with? (select any/all that apply)

Time management

Prioritising

Overwhelm

Burnout / Stress

Procrastination

Admin

Organisation

Consistency

Communication

Boundaries

Leadership

Performance concerns

Workplace conflict

Job search / career transition

Other

If other, please briefly explain here

Emergency Contact Details

Please provide someone we can contact if there's an urgent issue or emergency (even though it's unlikely to be needed)

Full name of Emergency Contact*

The person we should contact in case of emergency

Relationship to You

How is this contact related to you?

Emergency Contact Phone (Primary)*

The best number to reach them immediately.

Emergency Contact Phone (Alternative)

An additional number in case primary number is unavailable

Emergency Contact Email

We will only use this if we cannot reach them by phone

Name of GP & Surgery

Clinical diagnosis and wellbeing

Have you been formally diagnosed with ADHD or another neurodivergent condition? (ADHD, AuDHD, ASD, Dyslexia etc)

Yes

Self-diagnosed or waiting for assessment

Which conditions have you been diagnosed with?

ADHD

AuDHD

ASD

Dyslexia / Dyscalculia / Dyspraxia

Something else? Please give details below...

Are you currently taking ADHD medication?

Yes

Do you have any other conditions or diagnoses it would be helpful for me to know about? For example, anxiety, depression, burnout, chronic fatigue, PTSD, OCD, eating difficulties, sensory processing difficulties, or anything else that affects your daily life.

Please give details below, or tell me about anything else I should know about your life or circumstances

Rate the following areas of your life (these are a few safeguarding questions I need to ask)

	Not at all	Only occasionally	Sometimes	Often	Most or all of the time
I have felt tense, anxious or nervous
I have felt I have someone to turn to for support when needed
I have felt able to cope when things go wrong
Talking to people has felt too much for me
I have felt panic or terror
I made plans to end my life
I have difficulty getting to sleep or staying asleep
I have felt despairing or hopeless
I have felt unhappy
Unwanted images or memories have been distressing me

Client Wellbeing Questionnaire (CORE-10)

Your goals

What are the biggest changes you want to make in your life in the next 3 months?*

What are the biggest changes you want to make in your life over the next 1-3 years?*

What do you most want to achieve?*

And do you feel ready for it?*

Your History

Have you worked with an ADHD coach before or a similar one-on-one professional relationship?

e.g. sports coach, life coach, mentor, or therapist

Yes

What worked well for you?

What didn't work so well for you?

What major transitions have you had in the past two years?

A change in your relationship status, a new job/study environment, a new business, a new residence, bereavement, health issues etc.

My life

Who are the key people in your life, and what support do they give you?

On a scale of 1 to 10, rate the amount of stress/overwhelm in your life right now.

1 being the lowest amount of stress and 10 being the highest

1 = No Stress

10 = Extremely Stressful

What are your primary stressors?

List up to five things that you are tolerating or putting up with in your life at present.

(examples: info. you can’t find, clutter, poor friendships, fractured family relationships, unfinished tasks, job dissatisfaction, broken equipment, paperwork “piles”, etc.)

About you

List up to five adjectives that describe you at your best.

List up to five of your top strengths.

What are your hobbies and interests?

Do you currently do any regular exercise, sport, or physical activity?

Yes, regularly (3+ times a week)

Yes, occasionally (1-2 times a week)

Rarely

If yes, what do you do?

List your favourite activities to do on a day off:

Anything else you would like to share?

Consent*

I agree to the privacy policy.

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