Contact information
Your name
*
First Name
Last Name
Relationship to the adolescent
*
Email address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Name of your child
*
Child's birthday
*
-
Month
-
Day
Year
Date
What grade is your child in?
*
Your primary language
*
English
French
Other
Your child's primary language
*
English
French
Other
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Previous testing and diagnosis
Does your child have an ADHD diagnosis?
*
Yes
No
Has your child received a diagnosis for any other developmental disability?
*
Yes
No
If yes, what was the diagnosis?
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Medical information
Is your child currently on any prescribed medication for:
*
Anxiety
Depression
Tourettes
Hypertension
No medication
Other
Does your child have a history of any of the following:
*
Concussion/head injury
Epilepsy
Neurological conditions (i.e., meningitis)
Strokes
Heart problems
Kidney problems
No medical condition
Other
By completing this questionnaire, you are consenting our research staff to contact you regarding your child's eligibility for our program
*
Agree
Disagree
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