Welcome to our practice. In order to make the most of our time in this initial session, we would appreciate it if you would respond to the questions below. If there are things that do not apply, feel free to leave them blank or respond NA.

    Please return this form with your consent form. Thank you.
    1. What are the main reasons that you are seeking treatment at this time? Was there a specific event? Be as specific as you can.
    2. How well do you sleep?
    3. What medications and supplements do you take? For how long? • Please list the name and phone contact of the prescribing physician.
    4. Do you drink alcohol? • Frequency and amount?
    5. Do you use recreational drugs? Type, frequency and amount?
    6. Have you ever thought about or attempted suicide?
    7. Have you seen a counsellor, psychologist or psychiatrist? Please list in-patient and out-patient treatment.
    8. Do you live alone or with others?
    9. What is your occupation?
    10. Have you ever been diagnosed or had suspicion that you have either a learning disability or difficulty with attention?
    11. Please put a check next to the symptoms that apply: