Please complete and submit this form at least five business days prior to your initial consultation.

NOTE: Not all questions on this form require a response. If you wish to provide detailed answers to all questions this form may take 40 mins or more to complete. Thank you.

YOUR CONTACT DETAILS

Primary email

The address we will use to contact you regarding all important matters.

Google Email

We use Google Drive to share documents and resources with our clients. If you have a Gmail or Google Workspace account that we can use for this purpose, please provide your Google email address here.

Your Legal Name

First Name

Last Name

Preferred Name

Preferred Pronouns

Date of Birth

DD-MM-YEAR

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Number

Home Phone Number

Please list the names and email addresses of any other members of the household who will/may be attending appointments.

Billing name, address and email if different from above:

Emergency Contact

Please provide the name and phone number of someone your coach can contact if they are concerned about your wellbeing or safety

First Name

Last Name

Contact Number

YOUR PREFERENCES

Please select your coach

Catherine O'Kane

Andrée Morgan

Geoff Gawler

I don't mind - Any coach who has availability

What coaching or consulting service are you signing up for?

Coaching takes time to see results - on average, around 12 sessions. We recommend all new clients start off with this expectation in mind, and plan to start coaching by committing to at least 12 sessions. If for any reason you would like to stop working with your coach, you can do so at any time, and be refunded for any unused sessions you've pre-paid, subject to our appointment cancellation policy. We do ask that you try to give us as much notice as possible prior to cancelling an appointment. Thank you.

New coaching client package: starter-pack (12 sessions)

Introduction to ADHD (For those who want to learn more about ADHD): 1 to 4 sessions

ADHD Coach Business Mentoring

Other

If Selected Other

What is your invoicing preference?

All appointments are invoiced in advance. Payment is due two business days prior to each appointment or billing period to secure your booking. Any un-used credit for pre-paid appointments will be refunded upon request, subject to the appointment cancellation policy.

I would like to pay IN FULL, up-front for ALL sessions in the package I have chosen

I would like to pay in instalments and be invoiced in MONTHLY

I would like to pay in instalments and be invoiced in FORTNIGHTLY

I would like to pay in instalments and be invoiced in WEEKLY

What date would you be ready to commence coaching?

Please note that appointments are subject to availability.

If your initial appointment has not already been booked, how would you prefer to have your initial appointment?

Camberwell Specialists (In-Person)

Zoom/Google Meet (Online)

N/A - initial appointment already booked

How frequently would you like to meet with your coach?

We will do our best to accommodate your preference.

Weekly

Fortnightly

Other

If Selected Other

FURTHER DETAILS

This section is an opportunity for you to provide additional information about yourself and your life circumstances.

Referred by (if applicable):

What would you like to be different as a result of coaching? Do you have any specific goals in mind?

You, your family, household and key relationships

What would you like your coach to know about you, your family and the people who are important to you?

If applicable, your spouse/partner/significant other:

For example, you might wish to share "married to Sam for 4 years"

Your children:

If applicable, you may wish to share their names and ages plus any other relevant details here.

Pets:

ADHD, MENTAL HEALTH AND WELLNESS PROFILE

Having some background information before we start will provide some context to our initial discussions and allow us to get started a little faster. Please share as much or as little as you'd like to.

Have you been diagnosed with ADHD?

Yes

Seeking diagnosis

Suspected but not seeking diagnosis at this time

Other

ADHD Diagnosis Details

Please skip this section if not applicable

Date of diagnosis

Date does not need to be exact - a rough 'guesstimate' is fine.

YYYY

Who is on your 'ADHD Support Team'?

Who supports you with your ADHD? Family, friends, medical, allied health?

Would you like anyone who is on your support team to receive periodic updates from your coach regarding the work you do together?

For example, this may include your GP, psychologist, psychiatrist, a family member, or employer, etc. If yes, please provide their name and contact details, including email address, business address and phone number.

Health and Wellness

What things do you enjoy doing to maintain your health and fitness?

Is there anything else you'd like to tell your coach?

This is an opportunity for you to mention anything else you'd like to let us know, or that you think might be relevant.

SCHOOL, WORK and DOMESTIC RESPONSIBILITIES

"School" = all kinds of study or schooling, including TAFE, university etc

What do you do (or did most recently) for work, study and/or family responsibilities?

YOUR STRENGTHS and INTERESTS

What are you good at?

Some prompts to get you thinking: What skills or abilities have your practiced? What do people compliment you on? What comes easily to you? What is something that you're proud of accomplishing, and why?

What do you enjoy doing, or find rewarding?

NATIONAL DISABILITY INSURANCE SCHEME (NDIS)

For further information see: https://www.ndis.gov.au

In 2022 NDIA introduced new Pricing Arrangement and Pricing Limits.

NDIS Pricing Arrangements and Price Limits are outlined on the following page: https://www.ndis.gov.au/providers/pricing-arrangements#pricing-updates. The NDIS Support Catalogue lists all available supports and the price limits that are applied to each. Price limits are the maximum prices that registered providers can charge NDIS participants for specific supports. Pricing Arrangements and Price Limits must be followed when supports are delivered to NDIA-managed or plan-managed participants. If your NDIS funding is NDIA or Plan Managed and you wish to use your NDIS funding to wholly or partially cover the cost of your coaching sessions, we ask that you confirm with your LAC or Plan Manager/NDIA which Support Item Code you will use to cover your coaching sessions, and what, if any, hourly price limit applies, prior to your initial appointment.

Will you be engaging your coach under a NDIS plan?

No (please skip to the next section)

YES

UNSURE - I need to confirm if coaching is covered by my NDIS plan (please answer the following questions as best you can)

If YES or UNSURE:

Please indicate how your Plan is managed:

Self Managed

Plan Managed

NDIA Managed - Please note ADHD Partners is not a NDIA Registered Provider and you will not be able to pay for coaching with us under your plan

What is your NDIS plan number?

Have you reviewed the Price Arrangements and Limits, and sought clarification about which Support Item Number you are able to claim ADHD Coaching under:

Yes

If you are Plan Managed, which Support Item Number(s) have your Plan Manager advised you to use for coaching invoices?

If you have a Plan Manager, please provide their invoicing email address, website, and phone number.

What objectives under your NDIS plan would you like support working towards?

How do you wish to be supported to meet these objectives?

FEEDBACK

How did you find us?

Please select from the drop down list

Do you have any feedback or comments regarding this form?

We strive for continuous growth and improvement. Your thoughts would be appreciated.

Please check your "Spam" or "Junk" folders if you haven't received anything from us prior to your first appointment. We recommend that prior to hitting the "send" button you print a copy of this page to pdf as a backup copy for your own records prior to submitting your response.

Thank you! Your form has been submitted.

Please check your "Spam" or "Junk" folders if you haven't received anything from us prior to your first appointment.

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