Student Information Form
Student's Name
First Name
Last Name
Student's Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Age
Grade
School
What are your interests and hobbies?
What accomplishments make you the proudest?
Do you belong to any clubs, sports teams, etc?
If yes, please provide a list.
Are you employed part-time?
If yes, please provide details.
List all of the class periods and subjects you are currently taking in school.
What are your favorite subjects in school? Why?
What are your least favorite subjects in school? Why?
Are you currently taking private lessons or working with a tutor? If yes, please describe.
Has anyone ever explained ADHD to you so that you really understand it?
Describe how your ADHD affects you (BOTH positively and negatively).
Have you read any books or websites on ADHD for teens and adults? If yes, what did you find most helpful?
How do you think you learn best (check one)
Visual (using your eyes)
Auditory (using your ears)
Kinesthetic (hands-on learning)
What do you hope to gain from coaching sessions? (Check all that apply)
Set and meet goals
Learn organizational skills
Improve study habits
Improve grades in school
Spend less time on homework
Have more free time
Improve social skills
Make more friends
Learn how to stay healthy
Get into college
Find a job that you enjoy
Other
What would you like to do after high school?
Have you ever worked with a coach?
Do you understand that coaching is not therapy?
Do you have trouble getting to sleep?
Do you have trouble getting up in the morning?
What time do you get up in the morning?
Do you eat breakfast and lunch each day?
Do you have a routine for getting ready for school? If yes, please explain.
Do you have a routine for getting ready for bed? If yes, please explain.
When do you take your medication?
Morning
Noon
Evening
Bedtime
I don't take medication
I don't take it on a schedule
Do you take it independently or with help from your parents?
Please share with me anything else you think it would be helpful for me to know about you.
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