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:
anxietyangerincreased appetiteeasily frustratedheart palpitationsdifficulty readingdecreased appetitedifficulty focusingfeelings of helplessness

Dated

Full Name