ADHD Support Needs Assessment

Personal Information

Name Date of Birth Contact Information

Diagnosis & History

Have you been diagnosed with ADHD? Yes No If yes, when were you diagnosed? Other relevant diagnoses

Current Challenges

Attention & Focus (describe any challenges) Hyperactivity & Impulsivity Organization & Time Management Academic or Work Challenges Social or Emotional Challenges

Current Supports

Medications (if any) Other Professionals Involved (therapist, coach, etc.) Current Accommodations or Supports

Support Needs & Goals

Areas where you need more support What goals would you like to work toward?