Full Name *

Patient DOB *

Race (Person needing care) *

Select Option

Ethnicity (Person needing care) *

Select Option

Phone *

Email *

When is the best time to contact you?

Preferred way to communicate *

What's your goal? *

I am interested in *

What do you want the most help with? *

What do you want help with but it’s a close second priority? *

Mental health takes time, are you willing to commit time and to change some patterns like screen time exposure and sleep? *

Yes

How long have you been going through this? The more specific you are the faster we can get you relief. Your history is important so we can help brighten your future. *

How much nutrition do you get on a daily basis from fruits, vegetables and non-refined foods? *

10%-20%

20-30%

40%-50%

50% or more

We will be helping you create and manage healthy routines. Tell us about your social life, is it, check as many as apply *

I See Friends or Family a Few Times a Month

I Spend at Least 50% of My Down Time With Friends and Family

I am Mostly Isolated, I Live Vicariously Through the Shows I Watch

Almost Completely Electronic (text, social media, etc), No Shared Meals with Others

I Go Out All the Time, But I Never Feel Connected

Have you been treated for substance use (addiction, alcoholism) in the past?

Yes

Share the Dates Below *

What Medication are you taking currently? *

What is the most important goal you want us to help you achieve? The immediate future - the next 60 days. *

What’s the next most important goal you want us to help you achieve? The next 1-2 years. *

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