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Hello Doctor, How are you? I am doing a lot better with a lot of improvement. The audio has helped me a lot. Thank you.

Jasmin 

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INTAKE  FORM

A) Identification

Date of Birth
Month
Day
Year
Relationship Status
Address

B) Reason for Consultation

Is this for you or someone else?
Myself
Someone else
Have you previously received therapy/counselling/medical care?
Yes
No
Are you currently taking any medication?
Yes
No
Are you currently using supplements, herbal products, or sleep aids?
Yes
No
Do you currently use any of the following?
Any previous detox/rehab?
Yes
No

C) Physical Health Conditions (Medical)

Select if you have any of the medical conditions below.

D) Mental Health History & Current Symptoms

Have you ever been diagnosed with, or experienced, any mental health condition?
Yes
No
If yes, select all that apply:

E) Medication, Supplements, and Current Care

Upload Health Reports

Medical reports

Areas of Concern

Safety Screening (Required)

In the past 12 months have you had thoughts of self-harm or suicide?
Yes
No
Have you attempted self harm or suicide?
Yes
No
Do you currently feel unsafe or at risk of harming yourself or someone else?
Yes
No
Have you experienced severe symptoms recently (hallucinations, paranoia, mania)?
Yes
No

How will you describe the life without the issues? The way you will think, feel and act.

Honesty + Consent (Mandatory)

Do you have any current or past medical conditions?
Yes
No
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