BEST Program Form - ADHD Centre for Women

ADHD Best Program Form

Legal Name(Required)

First Last

Preferred Name

Preferred Pronouns

Date of Birth(Required)

Phone(Required)

Email(Required)

Work

Full-Time

Part-Time

School

Full-Time

Part-Time

Year(Required)

Month(Required)

What other health conditions do you have?

What management strategies have you tried?

Past Medications

Past non-medication treatments

What management strategies are you currently using?

Current Medications

Current Non-Medication Treatments

What are you hoping to gain from this program?

Cost per month

Price: $ 59.00 CAD

Payment Method