Do You Have Problems with Focus?

Name *

First

Last

Phone

Email *

Are you prone to forgetting scheduled activities and/or required materials needed for daily use? *

Yes
No

Do you find that you make careless errors like misreading instructions or misscheduling yourself? *

Yes
No

Do you become so overwhelmed by prioritizing your to-do list that you routinely shut down and do nothing instead? *

Yes
No

Do your friends comment on how you are always interrupting them or ask you if you are even listening to them? *

Yes
No

Does it feel nearly impossible to get started on school assignments or household chores? *

Yes
No

Do you find friends are frustrated by your lack of replies to their texts? *

Yes
No

Does sitting down and concentrating require you to move you body to focus? *

Yes
No

Have you always struggled with meaningfully engaging with projects, not due to lack of interest, but due to difficulty in sustaining your effort and/or getting started on something? *

Yes
No

Do you tend to interrupt others when conversing? *

Yes
No

When you were a child, did teachers or parents comment you weren’t living up to your potential or were in your own world and frequently forgetful/disorganized? *

Yes
No

Did you answer "yes" to 3 or more? *