Initial Intake
This initial assessment form will give our providers an overview of your unique story, the challenges you're currently facing and what you're expecting from working with us. There is no judgement here. Feel free to share as much or as little as you like. Just be honest.
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Email *
How did you hear about us? *
Have you seen a mental health professional before? 
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If yes, have you ever been hospitalized for mental health reasons? *
Are you currently on pyschiatric medication? *
Do you have any current or prior medical issues?
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What other medications are you taking?  Specify all medications and supplements you are presently taking and for what reason. *
What was life like as you were growing up, both at home and in school?
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Tell us more about your educational background. *
What is your current occupation? What do you do? How long have you been doing it?
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Who is in your family? What is your relationship with them like?
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Describe your current living situation. Do you live alone, with others, with family ...?
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What social activities and relationships do you engage in?
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Do you now, or have you ever, used alcohol, tobacco, recreational drugs, or prescription medication other than as prescribed?
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What are some of the current challenges you are facing and how 
What else would you like for us to know?
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Please list someone we can reach in case of an emergency. *
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