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Application for the Breakthrough Academy
Thank you for your interest in learning about how our community of Women with ADHD can help you learn to work through the barriers living with ADHD has created for you.

Once you've completed the application we'll review the answers and follow up with you regarding next steps.

Here's a link to the program you're applying for http://brianraymondking.com/programs/
Email address *
First and Last Name *
Your answer
What is my biggest challenge right now? (Please explain the ways it impacts your life) *
Your answer
Why am I seeking help now? *
Your answer
How will I know when I have achieved what I want? *
Your answer
On a scale from 1 -10 (10 being the strongest) How upset do you feel having this problem? *
Your answer
How do I feel about working with other women in a support community to solve this problem? *
Your answer
What do I think I could contribute to the aforementioned community? *
Your answer
What are my personal and professional goals? *
Your answer
What am I willing to do to achieve my goals (be specific). *
Your answer
What are my personal and professional strengths? *
Your answer
What is holding me back? (e.g. unhealthy relationships, recurring problems, limiting beliefs, unproductive habits, disorganization, etc.) *
Your answer
What accomplishments am I most proud of in my life and why? *
Your answer
What I most want to get out of my experience with the Breakthrough Academy? *
Your answer
How will I know I am getting it? *
Your answer
Please note any other issue that are important for us to understand about you (e.g. physical, psychological, belief issues) *
Your answer
Are you ready, willing and able to invest from $150-$300 per month to achieve your goal(s). *
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