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ADHD Rapid Transformational Coaching Program Enrollment Form

Thank you for choosing to enroll in our ADHD Rapid Transformational Coaching Program. We are excited to accompany you on this transformative journey towards managing ADHD with resilience and success.

Please complete the following enrollment form to ensure we tailor the program to your specific needs. Your responses will remain confidential, and this information will only be used to enhance the quality of your coaching experience.

Email^*

Personal Information

First Name^*

Last Name^*

Phone Number^*

Birth Date^*

mm/dd/yyyy

Address

Address Line 1 ^*

Address Line 2

City ^*

State or Region ^*

Country ^*

Zip ^*

Emergency Contact

Emergency Contact Name^*

Emergency Contact Number^*

Emergency Contact Relationship^*

Health Information

Do you have any medical conditions or allergies we should be aware of? If yes, please provide details:^*

Are you currently taking any medications? If yes, please provide details:^*

Program Preferences

Preferred Start Date^*

Best time of day for sessions^*

Preferred day of the week for weekly sessions^*

Do you have any specific preferences or expectations for the coaching sessions?^*

Payment Information

Please choose your preferred payment option^*

Full Payment: $2500 + HST
Payment Plan: $3500 + HST (Deposit: $1977.50, Instalment 1: $988.75, Instalment 2: $988.75) Request (Instructions will be emailed upon form submission)

Payment Method^*

Credit/Debit Card
Bank Transfer (e-Transfer to [email protected])

Additional Comments or Questions

Please use this space to communicate any additional information, questions, or concerns you may have.^*

Declaration^*

I acknowledge that the information provided in this enrolment form is accurate to the best of my knowledge. I understand that this program involves personal coaching sessions and may include therapeutic components. I am committed to actively participating in the program to achieve positive results.

I agree

Participant's Digital Signature^*

Todays Date^*

Please submit the completed form upon filling it out. Once we receive your enrolment form, we will provide you with further details on the program and the next steps.

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