ADHD Support Request | Safe Space to be Me

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ADHD Support Request

Please fill out the following form.

All information will be treated as confidential.

First name*

Last name*

Date of birth

Country/Region*

Address*

City*

Zip / Postal code*

Phone*

Email*

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

Yes

Is there a particular area of your ADHD you would like support with?*

Emotional Disregulation

Emotional Dysfunction

Other

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

Would you like them to know?

Yes

If you would like then to know, can you tell us why?

If you would prefer they didn't know, can you explain why?

Would it be helpful for your employer to have additional training on the best way to support you or other individuals with ADHD?

Yes

Would you like us to reach out to them, without disclosing your name/personal information?

Yes

If yes, provide their contact information, including their business name, telephone number or email address.

028 9620 8284

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