Intake form

Help us serve you better

Name *

Email address *

What is your age?

What is your gender?

What is your primary concern?

Please select at least one option.

ADHD

Depression

Anxiety

Stress

Other emotional disorders

Have you previously received any psychological assessments?

If yes, please provide details about the assessments.

Are you currently taking any medication for mental health issues?

If yes, please specify the medication(s).

Do you have any history of mental health disorders in your family?

If yes, please describe the relationship and the disorder.

What are your goals for seeking assessment or treatment?

Please list any additional concerns or questions you may have.

Additional questions or comments

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Downtown Behavioral Neuroscience and Psychology