Bay Area Center for ADHD Contact Form

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This form is confidential and HIPAA secure. Bay Area Center for ADHD is a specialty center of the Institute for the Advancement of Psychotherapy.

Name *

Email *

Phone Number *

Where are you located? *

Where are you seeking services?

Please select all that apply. If you are open to both in-person and remote sessions, please indicate this below.

San Francisco

Marin

East Bay

Peninsula

South Bay

Remote (Anywhere in the State of California via Zoom)

Other:

Required

How can we help you? *

Are you seeking service for a (can check more than one): *

child (less than 12 yrs old)

adolescent (12 to 18yrs old)

young adult (18 to 25 yrs old)

adult

family

couple

Other:

Required

Are you seeking (can check more than one; for more information about the types of assessments, go to our assessment page):
*

assessment option 1 - clinical assessment (shorter - just want to know if its ADHD/ADD)

assessment option 2 - a psychoeducational evaluation (longer - documentation needed for accommodations)

assessment option 3 - medication evaluation (assessment medication only treatment or to take to a health professional for medication)

medication treatment

coaching/therapy

family therapy

couples therapy

Other:

Required

How were you referred? *

Google

Therapist

Medical Professional (e.g., General Practitioner, Pediatrician, Nurse)

School

Friend/Family

Psychology Today

Other Online Source

Not Sure

Other:

Please list the specific referral source (google search term, friend, facebook group, specific doctor, psychiatrist, general practitioner, therapist, school, or other; please include name of referral source). If you're not sure, you can just write "not sure" *

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