Participant Information
Fill out the form carefully for registration
Patient Name
*
First Name
Middle Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
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2016
2015
2014
2013
2012
2011
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1925
1924
1923
1922
1921
1920
Year
Gender
*
Please Select
Male
Female
N/A
Patient Email
*
example@example.com
Contact Number
*
DSM-V Diagnosis: (if you are aware of it)
Current Employment Status
Student
Pensioner
Unemployed
Full-time employed
Part-time Employed
Self-Employed
At Home
Do you plan to use your medical aid for payment of this treatment?
No
Yes
Medical Aid
Medical Aid Option
Membership Number
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Your Treating Therapist's Details
Who is your treating psychiatrist?
Where is your psychiatrist located?
Contact details of treating psychiatrist:
Who is your psychologist?
Where is your psychologist located?
Contact details of psychologist:
Who is your GP?
Where is your GP located?
Contact details of GP:
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Clinical Information
What is your main reason for enquiring about this treatment?
How many episodes of depression have you had in your life?
One
Two
Three
More than three
Have you ever been admitted to a hospital or clinic for depression?
No
Yes
How many times?
Once
Twice
More than twice
When was your last admission?
*
Have you engaged in self-harm in the last three months?
No
Yes
Please specify
*
Do you use any substances?
No
Yes
Please specify
*
Have you ever had a psychotic episode?
No
Yes
Please specify
*
Have you been diagnosed with PTSD (Post-Traumatic Stress Disorder) or experienced a traumatic incident?
No
Yes
Please specify
*
For any queries, please contact us at info@drmelanevanzyl.com.
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