Falcons ADHD Plus — Let's See If You're a Fit

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First Name* This field is required.
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Last Name* This field is required.
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Email Address* This field is required.
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Phone Number* This field is required.
Mobile Number
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State of Residence* This field is required.
Colorado
North Carolina
Other
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Are you 18 years of age or older* This field is required.
Yes
No
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Which services are you interested in?* This field is required.
ADHD Management
Clarity Protocol (ADHD)
Founder's Focus
GLP-1 / Weight Loss
Hormone Optimization
Peptide Therapy
Not sure yet
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Are you seeking insurance-based care?
Yes
No
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In the last 30 days, have you had thoughts of harming yourself or others, or been in a psychiatric crisis or hospitalization?* This field is required.
Yes
No
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Have you ever been dismissed from care by a provider for medication misuse, diversion, or not following treatment?* This field is required.
Yes
No
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Have you ever been diagnosed with schizophrenia, schizoaffective disorder, or Bipolar I disorder?* This field is required.
Yes
No
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Are you currently experiencing psychosis, hallucinations, or delusions?* This field is required.
Yes
No
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Are you currently receiving controlled substance prescriptions (including for opioid use disorder, chronic pain, anxiety, or sleep) from another provider?* This field is required.
Yes
No
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In a few sentences, what's going on and why are you reaching out now?* This field is required.
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How did you hear about us?* This field is required.
Please Select
Please Select
Google
Social Media
Friend or Family Referral
Provider Referral
Other
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Anything else you'd like us to know?
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Telehealth readiness* This field is required.
I confirm I have a private space, a working camera and microphone, and reliable internet for video visits.
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I acknowledge Falcons ADHD Plus is a cash-based practice. We do not bill insurance for appointments or labs. If your insurance covers medications at a local pharmacy, we can submit a prior authorization — this is included in your monthly protocol fee. Not yet a patient? PA submissions are a one-time $50 fee.* This field is required.
I acknowledge and accept the cash-based model.
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By providing your phone number, you consent to receive text messages from Falcons ADHD Plus at the number provided. Message and data rates may apply.* This field is required.
Yes, I consent
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Your information is protected under HIPAA. Falcons ADHD Plus has a Business Associate Agreement with Jotform to keep your information secure.
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I'd like Falcons ADHD Plus to follow up with me even if I don't move forward right now. I understand I can opt out at any time by replying STOP to text messages or emailing admin@falconsadhdplus.com.
Yes
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Name
First Name
Last Name
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Date
Date of Birth
Month
Day
Year
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Date of Birth* This field is required.
Date
Month
Day
Year
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Falcons ADHD Plus is a 100% telehealth practice* This field is required.
I acknowledge and accept the cash-based model.
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