Information Request Form

Please complete the form, and we will contact you within 24 hours.

Request Information Regarding: *

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Education: Last Grade Completed (Before college)

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Do you currently use psychotropic medications?

Briefly complete the following:

1. Please describe the current problem.

2. What have you done about it?

3. What are your expectations of meeting with us?

4. What led you to seek help now?

5. As you see yourself, what kind of person are you? Describe yourself.

6. Is there any other info we should know?

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