Brain-Based ADHD Parenting Program™

Parent Fit Application – See if This Program Is a Good Fit

This short form helps determine whether the Brain-Based ADHD Parenting Program™ is a good fit for your family. Please include your contact information so we can reach you if the program appears to be a good fit.

Parent Contact Information

Parent/Guardian Name:

Email Address:

Phone Number:

City/State:

Child Information

Child's Age:

Has your child been diagnosed with ADHD?

Yes

No

Suspected

Question 1

What challenges are you currently experiencing with your child?Please briefly describe the biggest challenges you are facing (behavior, emotional regulation, routines, school difficulties, etc.).

Answer

Question 2

If things improved, what would you most want to be different in your home?If this program worked well for your family, what positive changes would you hope to see?

Answer

Question 3

Question 4

Are you ready to learn and apply new parenting strategies over the next 8 weeks?

Yes — I’m ready to try new strategies

Maybe — I would like to learn more

Not sure yet