Intake Form

Name

First Name

Last Name

Email

Subject

What medications or medicinal herbs are you taking? (For medications, please include dosage, frequency, how long you've been taking them, and what condition they are for)

How is your current emotional state?

How is your current physical state?

Please share about your mental health history. Have you been diagnosed with or do you think you may be suffering from bipolar disorder, schizophrenia or any other mental health conditions?

Have you had (in the past couple of years) made plans to attempt suicide?

Your emergency contact? Full name and phone number please.