Parent Information Form
(COMPLETED BY A PARENT OR GUARDIAN)
STUDENT INFORMATION SECTION
Student's Name
*
Nickname
Student Email Address
*
Enter parent email if student does not have one
Student's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Home Number
-
Area Code
Phone Number
Student Cell Number
-
Area Code
Phone Number
Age
Birthdate
Grade
Siblings in the home (names and ages)
School Name
School Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Phone Number
-
Area Code
Phone Number
Guidance Counselor
Guidance Counselor Phone Number
-
Area Code
Phone Number
Case Manager
Case Manager Phone Number
-
Area Code
Phone Number
Primary Health Care Provider
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Care Phone Number
-
Area Code
Phone Number
Mental Health Care Provider
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mental Health Care Provider Phone Number
-
Area Code
Phone Number
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PARENT INFORMATION SECTION
Parent 1 Name
Parent 1 Occupation/Employer
Parent 1 Home Phone
-
Area Code
Phone Number
Parent 1 Work Phone
-
Area Code
Phone Number
Parent 1 Cell Phone
-
Area Code
Phone Number
Parent 1 Email Address
example@example.com
Parent 2 Name
Parent 2 Occupation/Employer
Parent 2 Home Phone (if different)
-
Area Code
Phone Number
Parent 2 Work Phone
-
Area Code
Phone Number
Parent 2 Cell Phone
-
Area Code
Phone Number
Parent 2 Email Address
example@example.com
Guardian Name (if applicable)
Guardian Occupation/Employer
Guardian Home Phone
-
Area Code
Phone Number
Guardian Work Phone
-
Area Code
Phone Number
Guardian Cell Phone
-
Area Code
Phone Number
Guardian Email Address
example@example.com
Who were you referred by?
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Student History Section
When was ADHD Diagnosed?
Type of ADHD?
Name of Diagnostician
Are there any known learning disabilities or co-morbid conditions?
If yes, please explain.
Is the student currently taking medication for ADHD or any other related difficulty, such as depression or anxiety?
If yes, please explain
Please list any other medical conditions, including current treatment and medication.
Has the student ever worked with a coach or organizational consultant to assist with ADHD or LD problems?
If yes, what was the focus of the work?
Has the student worked with a tutor?
If yes, for what subjects?
Is the student CURRENTLY working with a tutor?
If yes, please list the days and subjects.
Please list any private lessons (dance, music, sports, etc) that the student participates in, and which days of the week the lessons or practices happen.
Are there other family members with an ADHD diagnosis?
If yes, please list their relationship(s) to the student.
Is there any family history of substance abuse?
Are you aware of alcohol or substance abuse in your teen (past or present)?
On a scale of 1-10, how well do you and your family understand ADHD?
Hover mouse for explanation of number range
Do you have a family calendar?
If yes, who usually keeps it current?
If no, are you willing to start using a family calendar when coaching begins?
Do you use a reward system with your child?
If yes, please describe.
If no, are you willing to work with the coach to develop a system?
Do you have any questions or concerns at this time?
Please share some personal thoughts about your child.
Please upload any relevant paperwork, such as psychoeducational testing report, IEP, 504 Plan.
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