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First name
Last name
Email
Phone
What are you currently dealing with? (check all that apply)
Fatigue or burnout
Anxiety / feeling on edge
Mood swings or irritability
Low motivation / feeling stuck
Sleep issues
Hormonal or cycle-related changes
Brain fog / focus issues
Relationship, intimacy, or sexual health concerns
Chronic pain or physical symptoms
How long has this been going on?
What is the primary reason you are seeking care today? (Please describe in your own words)
How much is this impacting your life?
Mild
Moderate
Significant
Severe
Have you tried treatment before?
No prior treatment
Therapy Only
Medication Only
Both Therapy and Medication
Multiple Treatment with little Improvement
Inpatient Hospitalization?
Currently taking any medications? Please list
Do you currently use any of the following? (This is a safe space — honesty helps us help you)
Alcohol
Cannabis
Nicotine/vaping
Medications not prescribed to you
Other substances
Current living situation:
Current occupation/student status
In a relationship?
Do you feel safe in your home and/or relationships? If no, please know we are here to help and this information stays with your care team.
What have previous providers gotten wrong or missed?
What do you most want your provider to understand about you?
In the past month, have you had any thoughts of harming yourself or ending your life?
NO
Yes, but with NO intention to act
Yes, with a plan
Have any of the following been part of your experience? (check all that apply)
High stress
Trauma History
Hormonal changes
Sleep problems
Chronic fatigue
Substance Use or Coping Behaviors
Major Life Transition
None
Do your symptoms follow a pattern?
Related to stress
Related to hormones/cycle
Comes and goes
No Pattern
Not Sure
Have you ever been diagnosed with a mental health condition? Yes / No If yes, please list all diagnoses you have received:
Are you open to a more comprehensive approach if needed?
Yes
Maybe
No
Preferred Pronouns
Anything else you want me to know before we meet?
Birthday
Month
Day
Year
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