Name *

First Name

Last Name

Phone

(###)

###

####

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Date of Birth

MM

DD

YYYY

Have you/your child been diagnosed with ADHD previously?

Yes

No

If YES (to being previously diagnosed) when were you/your child diagnosed?

As a child, age 5-12

As an adolescent, age 13-18

As an adult

No, I haven't been diagnosed previously

If YES (been previously diagnosed), were you or are you taking ADHD medication?

YES

NO