ADHD Support Request | Safe Space to be Me

ADHD Support Request

Please fill out the following form.

All information will be treated as confidential.

First name

Last name

Date of birth

Day

Month

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Email

Do you have an official diagnosis of ADHD or suspect you have ADHD?

Yes

No

Can you tell us more about this?

What, if any, are the barriers you face regarding work or education?

If relevant, does your work or place of education know or suspect you have ADHD?

Yes

No

As part of this service, a member of our team will ring you during office hours. Please let us know the best time to call you.

Permission to contact