LuxeMind ADHD Bootcamp

01

The Basics

Name

Email

Phone

Time Zone

Current role / work

02

ADHD Status

Diagnosis status

Formally diagnosed Self-diagnosed Suspected In process of diagnosis

Medication status

Taking medication Not taking medication Considering medication

03

Your Top Challenges

Pick your top 3 to 5 biggest struggles.

Other

04

Why Now?

What makes this the right time to invest in this program?

How did you hear about LuxeMind?

05

Understanding the Program

Please read before applying.

This program is

ADHD coaching focused on strategies, systems, and skills
Educational support for understanding your ADHD brain
A group learning experience with individual coaching sessions
Designed to help you build personalized systems that work for your brain

This program is not

Clinical treatment, therapy, or mental health counseling
A substitute for medical care or psychiatric services
Crisis intervention or emergency mental health support
Diagnostic services

When to seek clinical support

Please seek immediate professional help if you are experiencing:

Thoughts of harming yourself or others
Severe depression, anxiety, or other mental health concerns
Substance abuse issues
Trauma that requires clinical intervention

988 · Suicide & Crisis Lifeline Text HOME to 741741 · Crisis Text Line 911 · Emergency

06

Required Acknowledgements

Check all boxes to proceed with your application.

✓I understand this program provides ADHD coaching and educational strategies, not clinical treatment or therapy. ✓I understand this program is not a substitute for mental health care, medication management, or psychiatric services. ✓I understand I am responsible for my own decisions and actions during this program. ✓I understand I should seek clinical support if I experience mental health concerns that require professional intervention. ✓I have read and understand the crisis resources provided above. ✓I will actively participate in the program and understand I get the most out of it by what I put in. ✓Payment: I understand that full payment or a signed payment agreement must be completed prior to program participation. Access to the bootcamp will not begin until payment obligations are confirmed.

Signature (type your full name)

Date

Print Name

Bootcamp Application