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NEW PATIENTS: Complete the form below. A member of our team will be in touch within 1-2 business days.

Welcome to Forward Focus

Please take a moment to fill out and submit our ADHD New Patient Form.

First, we'd like to get to know you…

First Name

Last Name

Email Address

Phone Number

Are you between the ages of 18 and 50?

Yes, I am between the ages of 18 and 50. No, I am not between the ages of 18 and 50.

Do you live in Illinois?

Yes, I live in Illinois. No, I do not live in Illinois.

Do you plan on using insurance?

Yes, I will be using insurance. No, I will not be using insurance.

Next, please tell us about your health history…

Have you been previously diagnosed with ADHD?

Yes, I have been previously diagnosed with ADHD and I have documentation. Yes, I have been previously diagnosed with ADHD but I do not have documentation. No, I have not been diagnosed with ADHD before.

Have you been previously diagnosed with any of the following mental health disorders (select all that apply):

Do you feel like your ADHD symptoms are due to a concussion/head injury or multiple concussions/head injuries.

Yes, I feel like my ADHD symptoms are due to a concussion/head injury or multiple concussions/head injuries. No, I don't feel like my ADHD symptoms are due to a concussion/head injury or multiple concussions/head injuries.

Have you ever misused or abused substances and/or stimulants (e.g., ADHD medications) that have not been prescribed to you?

Yes, I have misused or abused substances and/or stimulants that have not been prescribed to me. No, I have not misused or abused substances and/or stimulants that have not been prescribed to me.

Do you currently have thoughts or urges to harm yourself and/or others?

Yes, I have thoughts or urges to harm myself and/or others. No, I do not have thoughts or urges to harm myself and/or others.

Have you previously ever attempted suicide?

Yes, I have previously attempted suicide. No, I have not previously attempted suicide.

You're almost done!

Please acknowledge that if you meet criteria for ADHD, you will be expected to follow up with an Innovative Care primary care provider for an in-person visit.

Yes, I acknowledge that I will be following up at Innovative Care with an in-person visit. No, I will be taking my results to another primary care provider.

Is there anything additional you’d like us to know? Please elaborate on any of your answers or provide additional information here.

Forward ADHD of Wisconsin

Contact Us

(608) 898-4818
brian@forwardadhd.com
221 King St. Ste 101, Madison, WI 53703

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