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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
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