ADHD Parent Coaching Form-April 6-May 18, 2026 Mondays: 12:30-2pm
To Register for the Calm and Connected ADHD Parent Coaching Class, 
please send $500 via:
Venmo: @justjabrams
Check: Email me at julieabramsotr@gmail.com for my address

I'd love to know a bit about you before we start.
Email *
Who is taking the class?
What is the name and ages of your children?
Where does your child go to school and what grade are they in?
What are you hoping to gain from the class?
Does your child have a diagnosis? 
Does your child have an IEP or 504?
Is your child seeing any other professionals?  If so, who?
What therapies or services have your done in the past? Were they effective?
Are you aware of any alcohol or substance abuse by your child (past or present)? If yes,
please detail.
Has your child at any time become physically abusive to you or others? If yes, please
detail.
Each session will be recorded on zoom and then sent out after the class in case I missed something or miss the class.  These videos are not to be shared.
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To help build a strong sense of community, it’s important for everyone to be an active participant in class. Please keep your video cameras on during each session.

If you’re unable to have your camera on, we kindly ask that you wait for the session recording instead of joining live.

Thank you for your understanding and commitment to creating a connected learning environment.

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Coaching Process and Disclaimer:
Coaching is designed to guide the Client to learn how to consistently achieve results and make purposeful choices. Client agrees to communicate honestly, be open to feedback and assistance and create the time
and energy to participate fully in the coaching program. However, due to the subjective nature of the
work, Client understands and agrees, that the Coach makes no guarantee as to the results Client will
achieve, nor is the Coach responsible for the results achieved by the Client from the coaching.

Client understands that coaching is NOT therapy and is not a substitute for therapy if needed, and does not
prevent, cure, or treat any mental disorder or medical disease.

Emergencies:
If there is a medical emergency- physical or psychological, DO NOT CONTACT THE COACH’S OFFICE.
Emergency issues must be addressed directly by your doctor or therapist, or by dialing 911 emergency
services if warranted.

Confidentiality and Privacy Agreement:
In order to make this service enjoyable and therapeutic for all who participate, it is necessary that both
Coach and Client agree to abide by all the rules listed below.
Coach agrees to maintain complete anonymity of all Client information disclosed or received from any third
party unless permission is received. If it is necessary for the Coach to gain access to information from
schools, therapists, physicians or other professionals, Coach will provide a standard information release form
for signature by the Client.
However, the terms of anonymity shall not apply where failure to disclose may be, in the Coach’s sole
discretion, in violation of any law or may involve information regarding certain crimes that have either been
committed or Coach believes may be committed, or when such information is subject to subpoena.
Coach and Client agree that Group is a safe space for members to exchange ideas, opinions and
comments in support of each other and their shared concerns.
During Client membership in a Calm and Connected workshop, Client may learn personal and confidential
information about individuals who participate or are involved with this Group.
Whether information is available to Client through the Group or accidentally, Client agrees to maintain
confidentiality and not reveal information to any person in the Group or outside the Group while Client is a
Member of the Group or at any time in the future when Client may no longer be a Member of the Group.
Client understands that breaking this agreement could result in the termination of Client’s membership with
the Group.

Although good faith efforts have been taken to preserve participant confidentiality, Coach makes no
guarantees in this regard or to information communicated by and between participants in this forum.

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Signature: (please type name below)
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