(408) 800-5736 6105 Snell Ave Suite 101 San Jose, CA 95123
Have you ever been diagnosed with a serious illness?
Please describe your overall health today
Have you ever been in a 12-step program? Please describe
Have you ever been in therapy before? When and how long? What was the focus of treatment?
Are you currently taking any prescription medications?
Thank you for taking the time to fill this out. Please bring this form along with the Informed
Consent as well as the name and number to whom the written report will be sent.