FAQ
Events
Reviews
About
Resources
Contact
RESERVE
FAQ
Events
Reviews
About
Resources
Contact
RESERVE
Client Intake Form
Full Legal Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Please provide your Primary Care Physician's name and address.
*
If you have a Therapist or Counsellor, please provide their name and contact information.
Do you give us permission to contact your therapist?
Yes
No
What are the problems for which you are seeking help?
*
What are the goals that you would like to achieve through the program?
*
Check the symptoms that you currently have.
*
Depressed Mood
Racing thoughts
Excessive worry
Unable to enjoy activities
Impulsivity
Anxiety attacks
Sleep pattern disturbance
Increase risky behavior
Avoidance
Loss of interest/motivation
Increased libido
Decreased libido
Hallucinations
Issues focussing
Decreased need for sleep
Suspiciousness
Change in appetite
Excessive energy
Excessive guilt
Increased irritability
Fatigue
Crying spells
Lack of self-acceptance
Weight gain
Weight loss
Chronic/recurring physical pain
Digestive issues
None of the above
Do you have any other symptoms that aren't listed above? If yes, please explain.
Do you have any allergies? If yes, please list them below.
Do you have any food intolerances or dietary requirements?
Please list all medications that you are currently taking or have taken in the past month, along with daily dosage and estimated start date.
Do you currently take any supplements? If yes, please list them with daily dosage.
How many alcoholic drinks do you consume per week?
*
Do you smoke (tobacco or marijuana)? If yes, please give details of frequency.
*
Do you regularly use street drugs? If yes, please list which one(s) and the frequency of use.
Have you ever abused non-prescription drugs?
*
Yes
No
Please list any past medical issues and hospitalizations.
Do you have any injuries that would affect participation in physical exercise? If yes, please give details.
Have you participated in a rehabilitation program before? If yes, please give details.
Email
*
Thank you for filling out the form, we will be in touch with more information shortly.
