Intake Form

Have you ever been diagnosed or suspect you have any of the following medical conditions? Required

Have you ever been diagnosed or suspect you suffer from any of the following psychiatric conditions?*

How often do you use alcohol Required

Dont drink alochol

every month or less

every week or less

every day

Have you used any of the following substances in the past 3 months? Required

Which of the following do you consider your support network?

Health History