Name
First Name
Last Name
Email
example@example.com
Phone Number
By providing your phone number, you consent to receive phone verification messages from Done.
Format: (000) 000-0000.
How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
*
Never
Rare
Sometimes
Often
Very Often
How often do you have difficulty getting things in order when you have to do a task that requires organization?
*
Never
Rare
Sometimes
Often
Very Often
How often do you have problems remembering appointments or obligations?
*
Never
Rare
Sometimes
Often
Very Often
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
*
Never
Rare
Sometimes
Often
Very Often
How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
*
Never
Rare
Sometimes
Often
Very Often
How often do you feel overly active and compelled to do things, like you were driven by a motor?
*
Never
Rare
Sometimes
Often
Very Often
Are you over 18 years old?
*
No
Yes
Have you had bipolar, psychosis, schizophrenia, suicidal attempts, cardiac conditions, or any mental hospitalization history in the past?
*
No
Yes
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Thank You
Thank you for taking the time to complete this form. A member of the Focus Now team will reach out to you shortly to schedule your consultation.We appreciate the opportunity to assist you and look forward to connecting with you soon.
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Thank You
We appreciate you taking the time to complete our assessment. Based on your responses, you do not currently meet the eligibility criteria for services at Focus Now.This determination is made to ensure that every individual receives the most appropriate level of care and support for their needs. While we are unable to move forward with services at this time, we encourage you to seek guidance from a licensed healthcare provider or a local mental health professional who can better assist you.Thank you for your understanding and for considering Focus Now. We wish you the very best in finding the care and support that’s right for you.
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