Contact Request for ADHD Coaching

Client Contact Information

First Name: *

Last Name * :

Preferred Name:

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Gender Pronouns: –None–She/HerHe/HimThey/ThemOther (Describe)

Gender Pronouns – Other:

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Phone: (Leave us your phone number so we can follow-up with you)

Email:

We have funding available to help those impacted by the COVID pandemic. If you require financial support for ADHD Coaching, please complete the questions below.

Because of the pandemic, I have been impacted financially: –None–YesNo

Because of the pandemic, my mental health has been impacted: –None–YesNo

Please explain how you have been impacted by the pandemic:

CanLearn may transfer personal information to outside service providers that perform services on our behalf such as client relations management systems, or similar services. These service providers are located and store data in Canada. By providing personally identifiable information to us, you agree to the transfer of your personal information to a server located in Canada. More information about our privacy policies and practices can be accessed by contacting Laura Godfrey at 403-686-9300 ext. 126 or by clicking here.