Studio Mindspace Self-Referral Form
Section 1: Contact Details
Please enter your contact information so we can follow up with the next steps.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
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Section 2: Consent
We’ll only reach out if you give us permission. You can opt out at any time.
Do you consent to Studio Mindspace contacting you by email with information relevant to your situation?
Yes
No
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Section 3: About You
Let us know who you are so we can direct you to the right team
Let us know which roles apply to you — choose all that fit. This helps us guide you to the most relevant options. You can select more than one.
*
I’m an adult
I’m a parent or caregiver
I’m a GP or clinician
I’m a manager or employer
I’m a professional or employee
I’m an educator or school staff member
Other
What kind of support are you seeking? Select all that apply
*
Comprehensive ADHD Diagnostic Assessment
Executive Function Screener (with automated PDF report)
ADHD Coaching or Group Programmes
Informational Resources (PDFs, videos)
1:1 Consultation (diagnostic or clarity consult)
Access to Public Webinar: “Executive Functioning, ADHD, and the Adult Brain”
Other
What kind of support are you seeking? Select all that apply
*
Full ADHD and Executive Functioning Assessment
Parent-Only Consultations
Post-Diagnosis Support (coaching, strategy planning)
Information Pack or 15-Minute Intro Call
Parent Workshop: “ADHD & EF in Kids: What Parents Need to Know”ADHD, and the Adult Brain”
Other
What kind of support are you seeking? Select all that apply
*
Full Clinical Assessment Referral Pathway
GP–Psychologist Consultation (case discussion)
Patient Support Options (coaching, group sessions)
GP Toolkit (screening tools, referral guidance)
CPD Seminar: “ADHD & EF Support for Primary Care”
Other
What kind of support are you seeking? Select all that apply
*
Executive Function Insight Report (with employee consent)
Confidential Manager Consultation
Coaching Programme for Employees
HR Guide to Executive Function in the Workplace
Team Workshop: “The Organised Brain: EF at Work”
Other
What kind of support are you seeking? Select all that apply
*
Executive Function Profile and Screening
1:1 Clarity Consultation
Executive Function Coaching Programme
EF Guide for High Performers
PD Workshop: “Brain Meets Business”
Other
What kind of support are you seeking? Select all that apply
*
ADHD/EF Assessment (with school input and caregiver consent)
Educator Guide (checklists and accommodations)
Professional Development Seminar for Schools
Staff Consultations or Classroom Strategy Sessions
(Includes EF Toolkit for classroom application)
Other
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Thank you — we’ve received your information
We’ll review your selections and be in touch shortly with more details about the next steps. If you have any specific questions, you’re welcome to add them below.
Is there anything else you’d like to tell us?
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