Men’s ADHD LAB Inquiry Form

Men’s ADHD LAB Inquiry Form
Today's Date

MonthDayYear
Date
Your Full Name
Your Birthdate

MonthDayYear
Date
Your Age
Your Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Your Email Address
example@example.com
Your Home/Billing Address

Street Address

CityState

Zip Code
Your age when diagnosed with ADHD?
Who made the diagnosis?
What treatment have you utilized or now are using?

Other
Your Highest Grade in School or College

Other
How did you hear about this group?

Other
If referred by a specific person, please give us their name.
What are your goals for this lab?
Anything else we need to know?
Lab Acknowledgments 1
Lab Acknowledgments 2
Your Preferred Group Start Time (90 minute; always on Wednesdays, 10 weeks)
My commitment level to joining this ADHD Lab
If you're a new patient to Dr Fulop's he will call to screen for lab suitability.

If you're a previous patient of Dr Fulop, and an adult with ADHD, you can likely join.
Dates Difference
Should be Empty:

Lab Acknowledgments 1