Name *

First Name

Last Name

Phone *

(###)

###

####

Are you

Self employed

Working for a company

Employed but wanting to start a side hussle or business

Between jobs

Would you describe yourself as (you can tick more than one)

Creative

Logical

A numbers operson

A people person

An ideas person

Someone who is doing what they would like to be doing

Someone who likes what they do but wants to start a business

Ambitious

Financially stable

Are you

Single

In a relationship (unmarried)

Married

Married with children

Divorced

Divorced with children

Divorced

Divorced with children

If you are in a relationship, is your relationship struggling?

No

Yes

Not presently in a relationship but previous relationships have been a struggle

Name the 1 st thing you would like to improve in your life to help all the other issues improve.

Better relationships

Earn more money

Feel less overwhelmed

Achieve success in my work

Feel better in my own skin

Are you able to commit to spending £1,250 (total) in order to be part of the ADHDMAX Mens Circle Group for the next 90 days?

Yes

No

I am happy to receive occasional emails from Max Lawrence regarding ADHD issues. *

Yes