Intake Survey

This form will be used to inform me of your current status to allow me to know you as well as possible before prescribing anything. Fill out as completely as possible. Every block is required, so if something is not applicable to you, put “not applicable” or “N/A”.

You may want to prepare your longer, more thorough responses and also save them in a MS Word document or Google Doc in case there is an email or website failure. It will also let you more easily edit it and review it before submitting.

Contact me with any questions regarding the form.