Name
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Phone
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(###)
###
####
Email
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Age
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Are you currently taking any medications, and if so, what?
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Are you currently on SSRIs or any other antidepressants? Have you ever been on them? If so, what was the dosage and when did you discontinue?
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Do you have any allergies?
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Please specify.
Do you have any previous and/or current medical conditions?
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Any family member medical conditions?
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Have you had any major surgeries?
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Please include year.
Have you been previously diagnosed and treated for your mental health?
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Any family member mental conditions, including substance abuse?
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Did you experience any trauma during childhood (psychological, emotional response to an event or an experience that is deeply distressing or disturbing)? What age?
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Please check any current symptoms
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Do you have a yoga, meditation, mindfulness, or similar practice? If so, for how long have you been engaged in it?
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Are you currently receiving therapy? If so, what brought you to it?
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Please include your therapist's name and contact information. This is for emergency purposes only.
Who is your emotional support network?
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Please provide names, phone numbers, and email addresses. We require that someone close to you know you are doing this work.
Anything else we should know health-wise that would help us in better supporting you?
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Please list any dietary restrictions (for ending meal)?
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