Registration Form for Braving ADHD Group
We live in a world largely created by neurotypical folks. Navigating and thriving in this world as someone who's neurodivergent is more than just a little challenging. It can feel damn near impossible. The constant feeling of shame, embarrassment, doubt, and lack of confidence can leave you feeling stuck and disconnected from others.

Our mission is to create a safe place to be yourself, express your pain/frustration while increasing your understanding, tools, and social connections. This group will be lead by an ADHD Coach &/or Therapist. We ask participants to commit to 6 Sessions Weekly for 75 min. The cost of the group will be based on the number of professionals leading the group.

Please complete this form if you are interested in participating in future groups. Once we have enough participates our staff will contact with you additional details.
Today's Date *
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Demographic & Contact Information
Client's Contact Information
Legal Name of Client (First and Last):
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Preferred Name
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Pronouns
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Required
Date of Birth (DOB):
 *
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Phone Number *
Email Address *
Street Address: *
City *
State *
Zip Code *
Zip What is your preferred method of contact? *
Required
Parent or Guardian's Contact Information
Required: For clients under the age of 18 or those requiring guardian consent, please kindly provide the contact information of your parent or guardian. We want to ensure that we have all the relevant information to support you and make your experience at Brave is as smooth as possible.

Optional: We understand that many young adults are still covered under their parents' health insurance or rely on their support to access mental health treatment. Providing your parent or guardian's contact information is essential for coordinating benefits checks, health insurance verification, and collecting credit cards and payment. This helps us ensure a smooth process, especially for those on their parents' health insurance or receiving financial support. Rest assured, your personal and financial information will be treated with the utmost confidentiality. We are here to support your mental health journey and look forward to providing you with exceptional care.
Legal Name of Parent or Guardian: *
Phone Number *
Email Address *
How did you hear about Brave's ADHD Groups?
 *
Required
What is the Name of the individual who referred you? 
[ First Name, Last Name ]
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