Name * First Name Last Name Pronouns Name you would like to be greeted when we meet if different from above Date of Birth * MM DD YYYY Email * Phone Country (###) ### #### Timezone Address * Address 1 Address 2 City State/Province Zip/Postal Code Country School/College Grade/Year Job What brings you here? Why are you interested in coaching? Are you neurodivergent? Which forms of neurodivergence are part of your life? Include yours or of people close to you. Self-diagnosis is valid. ex. ADHD, Autism, dyslexia, OCD, etc. Anything else you would like me to know? Parent/Guardian's Information if it applies Parent/Guardian's Name First Name Last Name Parent/Guardian's Email Parent/Guardian's Phone (###) ### #### Emergency Contact (Name) First Name Last Name Emergency Contact (Phone) (###) ### #### Emergency Contact (Email) Thank you! Client ProfilePlease fill in and return prior to our first session.
