Contact Request for ADHD Coaching

Client Contact Information

First Name: *

Last Name * :

Preferred Name:

Gender: –None–MaleFemaleUnknownNon-BinaryTransgenderIntersexPrefer not to discloseOther

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

Gender Pronouns – Other:

Street:

City:

Province:

Postal Code:

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

Email:

I am interested in finding out more about:

ADHD Coaching:

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.