Name *

First Name

Last Name

Medical diagnosis *

Psychiatrist Diagnosed ADHD (Inattentive type)

Psychiatrist Diagnosed ADHD (Combined type)

Suspect I have ADHD

Previously coaching / therapy for ADHD

ADHD coaching

Psychotherapy

CBT therapy

I consent to receiving email and sms from Max Lawrence Coaching *

Yes

Declaration on honour *

I honorably declare that all information I have provided is truthful and in no way misrepresents my circumstances or my life story. I understand that by submitting this form I am in no way entitled to any coaching without payment, that only a limited number of applicants will receive a free place.

If my application is not chosen for a FREE place on the program *

I would be interested in receiving a discount code to sign up with

Yes

No