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Patient First and Last Name

Phone Number

Age

What is your occupation?

What psychiatric conditions have you been diagnosed with in the past? (ex: anxiety, depression, OCD, postpartum anxiety, PTSD, ADHD, etc.) If none, put n/a

What psychiatric medications are you currently on? Put n/a if none.

In what ways have your medications helped? What are they not helping with?

What mental health symptoms are you wanting to target? (ex: depression, anxiety, low motivation, etc.)

What physical symptoms would you like to improve? (ex: fatigue, brain fog, GI issues)

In what ways have these symptoms made a negative impact in your life?

What are your top 3 mental health goals? (Be specific)

What do you think the biggest barriers are to reaching your goals?

What are you most excited about happening if over the next few months you start to feel better, mentally and physically?

How did you hear about me?

Friend

Acquaintance

Facebook

Licensed Professional

Instagram

Other

Would you consider yourself highly motivated to implement changes recommended to achieve your goals?

Yes

The investment to work 1:1 and receive premier level mental health services from an experienced mental health professional is a minimum of $1000 USD. I curate a very specialized treatment plan that best fits your unique needs in order for you to get the results you have been longing for. If we are a good fit, are you prepared to make that investment?

Yes

No, but I'd still like a consultation

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