Evolve Psychiatry New Patient Intake

1
Before You Begin

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The following questionnaire adapts to your answers and triggers clarifying questions when needed. The form takes approximately 10-20 minutes to complete.

Please submit at your earliest convenience but no later than NOON the business day before your consultation (Friday at NOON for all weekend appointments) to allow us time to review in advance and best prepare for your visit.

Consultations missing intake forms are at risk for being cancelled to make room for people on our waitlist who are wishing for a sooner appointment and have their forms done in advance.

We look forward to getting to know you!
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Name* This field is required.
First Name
Last Name
4
Email* This field is required.
example@example.com
5
Date of Birth* This field is required.
Date
Month
Day
Year
6
Allergies* This field is required.If there are no known allergies, enter "None."
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Emergency Contact Information* This field is required.
Full Name
Phone Number
Relationship
8
The information selected below may be disclosed to the designated individual.
(This is an optional section to add an additional contact; your emergency contact is not needed again.)

Full Name Relationship Phone Number

All Health Information Clinical/Progress Notes Lab Results Billing/Insurance Information Past/Present Medications Also add this person my emergency contact list
9
The information selected below may be disclosed to the designated individual.
(This is an optional section to add an additional contact; your emergency contact is not needed again.)

Full Name Relationship Phone Number

All Health Information Clinical/Progress Notes Lab Results Billing/Insurance Information Past/Present Medications Also add this person my emergency contact list
10
Current Medications (Both Psychiatric and Non-Psychiatric)* This field is required.Example: Prozac 60mg daily, Buspar 10mg twice a day, etc. Click on the + sign to add more rows. Write "None" if applicable.
11
What is the goal of your initial consultation?* This field is required.Your answer will trigger relevant additional history and active concerns questions.
Please Select
General mental health evaluation (no prior diagnosis or treatment)
Transitioning care for continuing medication management
Second opinion consultation (one-time visit)
Treatment for ADHD
Independent medical opinion needed for forms/letters/report
Treatment for substance dependency (alcohol, tobacco/nicotine, marijuana, prescription painkillers)
Only seeking referrals for counseling/therapy
12
Provide a brief description of your symptoms.
Huge
Large
Normal
Small
Ok
Ok
13
Situational Stressors* This field is required.Please check all of the following life circumstances that you think are significantly affecting your mental health from the past 24 months or need to be considered in the upcoming year.
Change in health or medical condition
Change in role or responsibilities at work
Change in financial security
Change in living accommodations
Change in relationship status
Conflict with loved ones or peers
Pregnancy/Birth of a child
Caring for special needs loved one
Graduating/transitioning institutions
Complex separation / divorce
Legal troubles
Death of a loved one
Other
14
Past Diagnoses* This field is required.Select only conditions that are officially diagnosed by a healthcare provider and can be backed by clinical documentation.
Self
Family Member(s)
Depression
Row 0, Column 0
Row 0, Column 1
Seasonal depression
Row 1, Column 0
Row 1, Column 1
Postpartum depression
Row 2, Column 0
Row 2, Column 1
PMDD
Row 3, Column 0
Row 3, Column 1
Bipolar 1 Disorder
Row 4, Column 0
Row 4, Column 1
Bipolar 2 Disorder
Row 5, Column 0
Row 5, Column 1
Generalized Anxiety
Row 6, Column 0
Row 6, Column 1
Social anxiety
Row 7, Column 0
Row 7, Column 1
OCD
Row 8, Column 0
Row 8, Column 1
Panic attacks
Row 9, Column 0
Row 9, Column 1
Agoraphobia
Row 10, Column 0
Row 10, Column 1
Separation anxiety
Row 11, Column 0
Row 11, Column 1
Compulsions / Addictions
Row 12, Column 0
Row 12, Column 1
Borderline Personality Disorder
Row 13, Column 0
Row 13, Column 1
Insomnia
Row 14, Column 0
Row 14, Column 1
Circadian Rhythm Disorder
Row 15, Column 0
Row 15, Column 1
PTSD / Nightmares
Row 16, Column 0
Row 16, Column 1
Eating Disorder
Row 17, Column 0
Row 17, Column 1
Anorexia
Row 18, Column 0
Row 18, Column 1
Bulimia
Row 19, Column 0
Row 19, Column 1
Binge Eating Disorder
Row 20, Column 0
Row 20, Column 1
Intellectual Developmental Disability
Row 21, Column 0
Row 21, Column 1
ADHD
Row 22, Column 0
Row 22, Column 1
Autism Spectrum
Row 23, Column 0
Row 23, Column 1
Dementia
Row 24, Column 0
Row 24, Column 1
Psychosis / Schizophrenia
Row 25, Column 0
Row 25, Column 1
Alcohol Abuse
Row 26, Column 0
Row 26, Column 1
Nicotine/Tobacco Use
Row 27, Column 0
Row 27, Column 1
None of the above
Row 28, Column 0
Row 28, Column 1
Depression
Seasonal depression
Postpartum depression
PMDD
Bipolar 1 Disorder
Bipolar 2 Disorder
Generalized Anxiety
Social anxiety
OCD
Panic attacks
Agoraphobia
Separation anxiety
Compulsions / Addictions
Borderline Personality Disorder
Insomnia
Circadian Rhythm Disorder
PTSD / Nightmares
Eating Disorder
Anorexia
Bulimia
Binge Eating Disorder
Intellectual Developmental Disability
ADHD
Autism Spectrum
Dementia
Psychosis / Schizophrenia
Alcohol Abuse
Nicotine/Tobacco Use
None of the above
Self
Row 0, Column 0
Family Member(s)
Row 0, Column 1
Self
Row 1, Column 0
Family Member(s)
Row 1, Column 1
Self
Row 2, Column 0
Family Member(s)
Row 2, Column 1
Self
Row 3, Column 0
Family Member(s)
Row 3, Column 1
Self
Row 4, Column 0
Family Member(s)
Row 4, Column 1
Self
Row 5, Column 0
Family Member(s)
Row 5, Column 1
Self
Row 6, Column 0
Family Member(s)
Row 6, Column 1
Self
Row 7, Column 0
Family Member(s)
Row 7, Column 1
Self
Row 8, Column 0
Family Member(s)
Row 8, Column 1
Self
Row 9, Column 0
Family Member(s)
Row 9, Column 1
Self
Row 10, Column 0
Family Member(s)
Row 10, Column 1
Self
Row 11, Column 0
Family Member(s)
Row 11, Column 1
Self
Row 12, Column 0
Family Member(s)
Row 12, Column 1
Self
Row 13, Column 0
Family Member(s)
Row 13, Column 1
Self
Row 14, Column 0
Family Member(s)
Row 14, Column 1
Self
Row 15, Column 0
Family Member(s)
Row 15, Column 1
Self
Row 16, Column 0
Family Member(s)
Row 16, Column 1
Self
Row 17, Column 0
Family Member(s)
Row 17, Column 1
Self
Row 18, Column 0
Family Member(s)
Row 18, Column 1
Self
Row 19, Column 0
Family Member(s)
Row 19, Column 1
Self
Row 20, Column 0
Family Member(s)
Row 20, Column 1
Self
Row 21, Column 0
Family Member(s)
Row 21, Column 1
Self
Row 22, Column 0
Family Member(s)
Row 22, Column 1
Self
Row 23, Column 0
Family Member(s)
Row 23, Column 1
Self
Row 24, Column 0
Family Member(s)
Row 24, Column 1
Self
Row 25, Column 0
Family Member(s)
Row 25, Column 1
Self
Row 26, Column 0
Family Member(s)
Row 26, Column 1
Self
Row 27, Column 0
Family Member(s)
Row 27, Column 1
Self
Row 28, Column 0
Family Member(s)
Row 28, Column 1
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Do you have a counselor or therapist currently?* This field is required.This includes individual or group and in-person or virtual providers.
YESNO
16
Counselor or Therapist Information
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Active ConcernsSelect up to 5 concerns occurring at least twice a week for the past 6 months. Skip anything that is currently stable.
Anxiety
Depression or unpredictable mood swings
Sleep disturbance
Addictive and/or compulsive behaviors
Anger or emotional outbursts
Trauma
Morbid or suicidal thoughts
Cognitive impairment
Eating disorder
None of the above
18
Quantity of Sleep* This field is required.
19
Which of the following do you incorporate in your bedtime routine?
reading a book
watching tv
scrolling on phone
eating a snack
drinking alcohol
smoking cannabis
smoking tobacco
I don't need anything special
Other
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Do you experience any of these frequent sleep disturbances?Only select any symptoms occurring at least twice a week for the past 6 months.
Difficulty initiating sleep
Nighttime awakenings
Difficulty resuming sleep
Difficulty waking up
Snoring
Restlessness in limbs
Ringling/Crawling sensation in limbs
None
21
Do you experience the following sensations immediately upon awakening?Only select any symptoms occurring at least twice a week for the past 6 months.
racing thoughts
fear for personal safety
fear for the safety of loved ones
not recognizing surroundings
disappointment at still being alive
none of the above
Other
22
Do you experience any of the following physical symptoms when you awaken?Only select any symptoms occurring at least twice a week for the past 6 months.
sore jaw
light sensitivity
dry mouth
excessive thirst
grogginess
headaches
neck/back pain
persistent fatigue
sweating
none of the above
Other
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Do you have triggers for routine sleep disturbances?* This field is required.Only select any symptoms occurring at least twice a week for the past 6 months.
interpersonal conflict
substance use
work/school stress
sleep deficit
nutritional deficit
seasonal changes
recalling past traumas
none of the above
Other
24
Are you experiencing any of the following emotional symptoms of mood changes?* This field is required.Only select any symptoms occurring at least twice a week for the past 6 months.
sadness
hopelessness
irritability
apathy
social isolation
feeling worthless
excessive guilt
thoughts of not wanting to live
thoughts of harming self
none of the above
Other
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Are you experiencing any of the following physical symptoms of mood changes?* This field is required.Only select any symptoms occurring at least twice a week for the past 6 months.
Insomnia
Daytime sleepiness
Excessive fatigue even with rest
Appetite changes
Diminished regard for grooming and hygiene
Hyperactivity / restlessness
Impulsivity
Forgetfulness / memory problems
Poor concentration
None of the above
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Are you struggling with motivation to do any of the following?* This field is required.Only select any symptoms occurring at least twice a week for the past 6 months.
going to bed
getting out of bed
personal grooming and hygiene
preparing or eating meals
keeping in touch with loved ones / peers
managing finances
maintaining household and caregiving of children or loved ones
maintaining professional responsibilities
maintaining academic responsibilities
none of the above
Other
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Have you ever experienced any of the following extreme symptoms of mood changes for more than 4 days in a row?* This field is required.Select answers if the symptoms lasted for more than 4 DAYS CONTINUOUSLY and were in the absence of any substance use.
little to no appetite
little to no need for sleep
racing thoughts
feeling hyperactive, restless, fidgety
extreme irritability
extreme euphoria
aggression
facial motor tics
unusual talkativeness
speaking very fast
feeling/looking flushed
engaging in dangerous stunts
exaggerated self-esteem
feeling you were someone else
a rush of grand ideas
paranoia
hallucinations
risky promiscuity
impulsive spending / travel
moving or speaking noticeably slow
disregard for personal hygiene
None of the above have ever lasted more than 4 days continuously
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Describe the general pattern in your mood changes.* This field is required.Select all that apply.
They are sudden and are generally not associated with any identifiable trigger.
They last only minutes to a few hours at most.
They are predictably tied to circumstances.
They are generally difficult to control compared to others.
They always last for weeks to months at a time and are challenging to endure.
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Are you experiencing any of the following symptoms frequently?* This field is required.Only select any symptoms occurring at least twice a week for the past 6 months.
Uncontrollable worrying about everyday things
Inability to relax
Racing thoughts
Restlessness
Muscle tension
Indigestion
Inattention
Foggy memory
Headaches
Falling ill frequently
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Have you been experiencing any of the following symptoms that come on suddenly?* This field is required.Only select any symptoms occurring at least twice a week for the past 6 months.
dizziness
fainting
tremors
sense of dread
nausea
flushing
sweating
chest tightness
palpitations
racing pulse
feeling suffocated
shortness of breath
None of the above
Other
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Do you have an intrusive thoughts about any of the following?* This field is required.Only select any symptoms occurring at least twice a week for the past 6 months.
germs or contamination
becoming severely/terminally ill
losing control
losing items
inflicting harm on others
disappointing others
making mistakes or suboptimal decisions
overlooking key details
offending others
humiliating self in front of others
superstitions
catastrophic misfortune
natural disasters
sexual‚ religious‚ or violent thoughts that are considered socially unacceptable
none of the above
Other
32
Do you feel compelled to repetitively engage in any of the following behaviors?* This field is required.Only select any symptoms occurring at least twice a week for the past 6 months.
repeating everyday actions a specific number or times or in a very specific way
washing or bathing of hands or feet
rearranging of objects to perfection
counting or repeating words/phrases
checking of house or card door lock
checking appliances, power outlets, faucets, light switches, etc
hair pulling
skin picking
collecting items of little or no value
none of the above
Other
33
Do you feel debilitated in any of the following social situations?* This field is required.Only select any symptoms occurring at least twice a week for the past 6 months.
making eye contact with others
being observed
being the center of attention
going to crowded event/place
meeting strangers
speaking in front of an audience
speaking to authoritative figure
confrontation
returning goods at a store or placing an order in person/drive-thru
none of the above
Other
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How often do you feel the following in social interactions?* This field is required.Only select any symptoms occurring at least once a week for the past 6 months.
Insulted
Excluded
Envious
Suspicious
Paranoid
Never
Rarely
Sometimes
Frequently
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3
Never
Rarely
Sometimes
Frequently
Row 1, Column 0Row 1, Column 1Row 1, Column 2Row 1, Column 3
Never
Rarely
Sometimes
Frequently
Row 2, Column 0Row 2, Column 1Row 2, Column 2Row 2, Column 3
Never
Rarely
Sometimes
Frequently
Row 3, Column 0Row 3, Column 1Row 3, Column 2Row 3, Column 3
Never
Rarely
Sometimes
Frequently
Row 4, Column 0Row 4, Column 1Row 4, Column 2Row 4, Column 3
Insulted
Excluded
Envious
Suspicious
Paranoid
Never
Rarely
Sometimes
Frequently
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3
Never
Rarely
Sometimes
Frequently
Row 1, Column 0Row 1, Column 1Row 1, Column 2Row 1, Column 3
Never
Rarely
Sometimes
Frequently
Row 2, Column 0Row 2, Column 1Row 2, Column 2Row 2, Column 3
Never
Rarely
Sometimes
Frequently
Row 3, Column 0Row 3, Column 1Row 3, Column 2Row 3, Column 3
Never
Rarely
Sometimes
Frequently
Row 4, Column 0Row 4, Column 1Row 4, Column 2Row 4, Column 3
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Do you excessively engage in any of following behaviors?* This field is required.Only select any bothersome symptoms occurring at least twice a week for the past 6 months.
gambling
shopping
playing video games
binge eating
exercising
setting fires
restricting dietary intake
thrill-seeking stunts
stealing possessions
watching pornography/strippers
sex with partner
sex with multiple strangers
none of the above
Other
36
Do you frequently experience any of the following preceding or during an emotional outburst?* This field is required.Only select any symptoms occurring at least ONCE A MONTH for the past 6 months.
explosive rage
increased energy
racing thoughts
numbness/tingling
tremors
fever
palpitations
shortness of breath/chest tightness
none of the above
Other
37
Do any of the following behaviors apply to you when you get angry?* This field is required.
shouting disproportionately
using profanity
gaslighting
launching long tirades
uncontrollable sobbing
threatening people or animals
throwing temper tantrums
stomping
slamming doors
slapping, shoving, or pushing others
needing to restrained
physically assaulting people or animals
damaging property
driving/behaving recklessly
none of the above
Other
38
Can you recall if you have had any of the following traumatic experiences?* This field is required.
Physical abuse or neglect as a child
Molested as a child
Bullying as a child
Witnessing acts of violence
Physical assault
Domestic violence
Sexual abuse as an adult
Transportation accidents
Sudden loss and grief
Intense medical emergencies or procedures
War, combat, or other forms of violence
Natural disasters
Emotional abuse or neglect
None of the above
Other
39
Have you experienced any of the following symptoms?* This field is required.Only select any symptoms occurring at least ONCE A MONTH for the past 6 months.
Repeat flashbacks
Difficulty recalling events
Avoiding related or similar places, people, or situations
intense distress at external reminder cues
Remaining vigilant of surroundings
Nightmares
Waking up startled
increased startle response
sense of foreshortened future
Feeling detached from surroundings and people
Persistent self-blame or guilt
Watching self in 3rd person
There is glass or force separating self from everything
Having lost control of speech or motion
Sensation of floating
Surrounding environment appear in 2D, blurry, or colorless
Time is moving slower
Recent events feel distant
None
Other
40
Describe any recurring nightmares.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
41
Do you ever have any of the following sensations?
feeling you are being watched or followed
hearing others voices that no one can hear
hearing voices telling to harm yourself or others
seeing people or objects that no one else can see
feeling others can hear your thoughts
feeling you can hear others thoughts
42
Do you ever have trouble remembering any of the following?* This field is required.Only select any symptoms occurring at least once a week for the past 6 months.
current day and/or time
present surroundings and/or circumstances
conversations or events that happened minutes ago
conversations or events that happened hours ago
conversations or events that happened days ago
annual or usual events that were typically easy to remember
how to do things that you used to know how to do
how to get to places that used to be familiar
none of the above
Other
43
Do you experience any of the following behaviors or sensations?* This field is required.Only select any symptoms occurring at least once a week for the past 6 months.
sudden loss of orientation to self‚ time‚ place‚ or surroundings
sudden trouble recognizing people or objects
losing train of thought in conversation‚ movies‚ books
difficulty recalling words or phrases just before speaking them
forgetting to eat meals
neglecting physical presence of others
unsafe driving
distorted sense of time passed
misplacing everyday objects
unintentionally leaving appliances on
unintentionally leaving doors unlocked
difficulty with prioritizing and decision making
decreased attention span
increased impulsivity
wandering in or out of the house
making socially inappropriate and/or sexual comments or actions
none of the above
Other
44
How frequently do you eat?* This field is required.
Regularly eat 2-3 meals a day
Can go more than 24 hours without eating
Eat one meal a day and no more
Can never go more than 3 hours without snacking or eating
45
How would you describe your weight relative to your average recommended weight range?
Please Select
Please Select
Within range
Less than 10 lbs below range
More than 10 lbs above range
More than 20 lbs above range
I am already diagnosed with obesity
46
Do you engage in any of the following eating patterns or behaviors?
Prefer being thinner over balanced nutrition
General distaste for food due to look, smell, or texture
Binge eating even with full
Distracting intake to exercise a sense of control
Eating alone to avoid embarrassment
Eating alone in the middle of the night
Regurgitating and chewing food again
Ingesting non-food substances
None
47
Do you use any of the following methods to prevent weight gain?
Exercising multiple times a day
Starving
Induce vomiting to regurgitate food
Laxatives to eliminate food
Enemas to eliminate food
Diuretics to urinate excessively
Caffeine pills
Appetite suppressing supplements
None
48
How frequently do you engage in these behaviors?
Please Select
Please Select
Every few years
At least once a year
At least once a month
Multiple times a week
49
How do you feel about your past attempts at diet and weight management?
Please Select
Please Select
Satisfied with well balanced diet
Frustrated after some benign attempts
Distress due to many serious attempts
Unconcerned at this time
50
Do you feel that your eating habits are due to any of the following psychosocial stressors?
Poor body image
Poor self-esteem
Feeling lonely
Intense fear of gaining weight
Criticized by others of being in denial
Being hypercritical of others
None
51
Do you feel that your eating habits could be a source of health risks?
Insomnia
Chronic fatigue
Dehydration
Difficulty concentrating
Abnormal blood sugar
Rapid weight fluctuations
Nutritional deficiencies
Obesity
Blood pressure changes
Shortness of breath
Gut discomfort
Infections
Irregular menstrual cycles
Difficulty getting pregnant
Hair loss
Skin changes
None
52
What substance would you like assistance with quitting?Select all that apply.
Alcohol
Tobacco/Nicotine
Marijuana/THC
Cocaine
Methamphetamine
Heroin
Fentanyl
Inhalants
Prescription stimulants (Adderall, Ritalin, Vyvanse, Concerta)
Prescription opioids/painkillers (Percocet, Vicodin, Norco)
Prescription sedatives (Ambien, Lunesta, etc)
Prescription benzos (Xanax, Valium, Restoril, Ativan, Klonopin)
Hallucinogens (PCP, Ecstasy, mushrooms, etc)
53
List your frequency of usage in the past 2 monthsSpecify average # of uses in a day and average # of days in a week
54
What complications of quitting are you needing assistance with?Select all that apply.
Behavioral support
Cravings
Moderate withdrawals (palpitations, GI upset)
Severe withdrawals (hallucinations, seizures)
General withdrawals (irritability, fatigue, nausea, headache)
55
Have you ever tried quitting before?
YESNO
56
What’s the longest period you were able to abstain?
Huge
Large
Normal
Small
Ok
Ok
57
What treatments have you tried in the past?Select all that apply.
Peer support (AA, NA)
Individual counseling
Group therapy
Residential treatment
Detox facility
Chantix
Naltrexone/Vivitrol
Buprenoprhone/Suboxone/Subutex
Nicotine replacement therapy (lozenges, patches, gums)
58
What else contributed to your abstinence?Select all that apply.
Family/friends support
Change of job/school
Change in relationship
Change in peers
Chantix
Naltrexone/Vivitrol
Buprenoprhone/Suboxone/Subutex
Nicotine replacement therapy (lozenges, patches, gums)
59
How frequently do your overall symptoms occur?* This field is required.
Every few years
At least once a year
At least once a month
Multiple times a week
Daily
60
In the past year how have the symptoms changed?* This field is required.
less intense, less frequent
less intense, more frequent
more intense, less frequent
more intense, more frequent
unchanged
61
How are these symptoms and behaviors affecting your life?* This field is required.
interference with work or academic tasks
upsetting daily routine
worsening memory recall and focus
damaging interpersonal relationships
increasing feelings of guilt and shame
endangering financial security
none of the above
Other
62
Is there anything that helps with your symptoms?* This field is required.
Change of physical environment
Change of surroundings
Change in social circle
Confronting/addressing situations
Improving lifestyle habits
Time
Counseling/peer support
Medications
Cannot find a solution
None
Other
63
What do you do for a living?* This field is required.Select all that apply.
Please Select
Employed full-time
Employed part-time
Self-employed
Full-time student
Part-time student
Military/veteran
Retired
On disability
Full-time parent/caregiver
Unemployed
64
Employment Details* This field is required.Help us understand your work environment.
65
Military Service* This field is required.Thank you for your service.
66
Highest level of education completed* This field is required.
Please Select
Please Select
Some high school
High school
Some college
College
Graduate School (MBA, Masters, Advanced Certificates)
Professional School (Medical, Law, Doctorate)
67
Academic Details* This field is required.Help us understand your academic environment.
68
Relationship Status* This field is required.
Please Select
Single
Married
Monogamous relationship/partnership
Polyamorous relationship
Separated
Divorced
Widower
69
Who do you live with?* This field is required.
Please Select
No one
Partner or spouse
Children
Sibling(s)
Parents(s)
Relative(s)
Roommate(s)
Friend(s)
70
What type of residence do you live in?* This field is required.
Please Select
Apartment
Single family house
Townhome
Dorm
Public housing
Assisted living
Nursing home
Mobile home
Homeless
71
What kind of geographic areas were you primarily raised in?
small town
suburban
urban
major metropolitan city
abroad
72
What is your religious affiliation?* This field is required.
Catholic
Christian
Jewish
Buddhist
Hindu
Muslim
Prefer not to answer
Other
73
Do you have any history or current use of any recreational substances?* This field is required.Select usage and frequency for any substances used currently.
Usage
Frequency
Nicotine (Tobacco/Vape)
Never
Current
Historical
Row 0, Column 0
Never
< 4x a year
once a month
2-3x a week
Daily
Row 0, Column 1
Alcohol
Never
Current
Historical
Row 1, Column 0
Never
< 4x a year
once a month
2-3x a week
Daily
Row 1, Column 1
Cannabis
Never
Current
Historical
Row 2, Column 0
Never
< 4x a year
once a month
2-3x a week
Daily
Row 2, Column 1
Synthetic THC
Never
Current
Historical
Row 3, Column 0
Never
< 4x a year
once a month
2-3x a week
Daily
Row 3, Column 1
Psychedelics
Never
Current
Historical
Row 4, Column 0
Never
< 4x a year
once a month
2-3x a week
Daily
Row 4, Column 1
ADHD stimulants without prescription
Never
Current
Historical
Row 5, Column 0
Never
< 4x a year
once a month
2-3x a week
Daily
Row 5, Column 1
Opioids (heroin, fentanyl, prescription painkillers)
Never
Current
Historical
Row 6, Column 0
Never
< 4x a year
once a month
2-3x a week
Daily
Row 6, Column 1
Cocaine
Never
Current
Historical
Row 7, Column 0
Never
< 4x a year
once a month
2-3x a week
Daily
Row 7, Column 1
Methamphetamine
Never
Current
Historical
Row 8, Column 0
Never
< 4x a year
once a month
2-3x a week
Daily
Row 8, Column 1
None of the above
Never
Current
Historical
Row 9, Column 0
Never
< 4x a year
once a month
2-3x a week
Daily
Row 9, Column 1
Nicotine (Tobacco/Vape)
Alcohol
Cannabis
Synthetic THC
Psychedelics
ADHD stimulants without prescription
Opioids (heroin, fentanyl, prescription painkillers)
Cocaine
Methamphetamine
None of the above
Usage
Never
Current
Historical
Row 0, Column 0
Frequency
Never
< 4x a year
once a month
2-3x a week
Daily
Row 0, Column 1
Usage
Never
Current
Historical
Row 1, Column 0
Frequency
Never
< 4x a year
once a month
2-3x a week
Daily
Row 1, Column 1
Usage
Never
Current
Historical
Row 2, Column 0
Frequency
Never
< 4x a year
once a month
2-3x a week
Daily
Row 2, Column 1
Usage
Never
Current
Historical
Row 3, Column 0
Frequency
Never
< 4x a year
once a month
2-3x a week
Daily
Row 3, Column 1
Usage
Never
Current
Historical
Row 4, Column 0
Frequency
Never
< 4x a year
once a month
2-3x a week
Daily
Row 4, Column 1
Usage
Never
Current
Historical
Row 5, Column 0
Frequency
Never
< 4x a year
once a month
2-3x a week
Daily
Row 5, Column 1
Usage
Never
Current
Historical
Row 6, Column 0
Frequency
Never
< 4x a year
once a month
2-3x a week
Daily
Row 6, Column 1
Usage
Never
Current
Historical
Row 7, Column 0
Frequency
Never
< 4x a year
once a month
2-3x a week
Daily
Row 7, Column 1
Usage
Never
Current
Historical
Row 8, Column 0
Frequency
Never
< 4x a year
once a month
2-3x a week
Daily
Row 8, Column 1
Usage
Never
Current
Historical
Row 9, Column 0
Frequency
Never
< 4x a year
once a month
2-3x a week
Daily
Row 9, Column 1
1 of 10
74
Have you encountered any of the following legal setbacks?* This field is required.(This is only to understand context of stressors and does not impact your consultation eligibility.)
Arrests
DUIs
Misdemeanors
Felonies
Jail
Prison
Parole
Probation
None
75
Describe any outstanding legal troubles. Include details on month/year, circumstances, and current status.* This field is required.(This is only to understand context of stressors and does not impact your consultation eligibility.)
76
How would you like to add in personal and family medical history?
There isn't much relevant history so I'd like to type it in myself.
I rather review all options to make sure I don't miss anything.
77
Please list all following relevant medical conditions and past surgeries for yourself and family medical history.
Medical Conditions and Surgeries (i.e. obesity, high blood pressure, seizures, hysterectomy, stents, etc.)
Family Medical History (i.e. Dementia (grandfather), High blood pressure (mother), etc.)
78
Do you or any family members have any health conditions in the following areas?* This field is required.Select all that apply.
Neuro/Brain
Cardiovascular/Heart
Respiratory/Lungs
Gastrointestinal/GI
Musculoskeletal/Muscles or Bones
Endocrine/Hormones
OB/GYN
Hematologic/Lymphatic/Blood
Infectious Diseases/STDs
Renal/Urological/Kidney/Bladder
None
79
Neuro/Brain
Self
Family Member(s)
Vertigo
Row 0, Column 0
Row 0, Column 1
Fainting Spells/ Syncope
Row 1, Column 0
Row 1, Column 1
Migraine/headaches
Row 2, Column 0
Row 2, Column 1
Head trauma/concussion
Row 3, Column 0
Row 3, Column 1
Sciatica
Row 4, Column 0
Row 4, Column 1
Neuropathy (numbness/tingling)
Row 5, Column 0
Row 5, Column 1
TIA
Row 6, Column 0
Row 6, Column 1
Stroke
Row 7, Column 0
Row 7, Column 1
Epilepsy/Seizures
Row 8, Column 0
Row 8, Column 1
Intellectual Disability
Row 9, Column 0
Row 9, Column 1
Essential Hand Tremor
Row 10, Column 0
Row 10, Column 1
Alzheimer's Dementia
Row 11, Column 0
Row 11, Column 1
Parkinson's Disease
Row 12, Column 0
Row 12, Column 1
Vertigo
Fainting Spells/ Syncope
Migraine/headaches
Head trauma/concussion
Sciatica
Neuropathy (numbness/tingling)
TIA
Stroke
Epilepsy/Seizures
Intellectual Disability
Essential Hand Tremor
Alzheimer's Dementia
Parkinson's Disease
Self
Row 0, Column 0
Family Member(s)
Row 0, Column 1
Self
Row 1, Column 0
Family Member(s)
Row 1, Column 1
Self
Row 2, Column 0
Family Member(s)
Row 2, Column 1
Self
Row 3, Column 0
Family Member(s)
Row 3, Column 1
Self
Row 4, Column 0
Family Member(s)
Row 4, Column 1
Self
Row 5, Column 0
Family Member(s)
Row 5, Column 1
Self
Row 6, Column 0
Family Member(s)
Row 6, Column 1
Self
Row 7, Column 0
Family Member(s)
Row 7, Column 1
Self
Row 8, Column 0
Family Member(s)
Row 8, Column 1
Self
Row 9, Column 0
Family Member(s)
Row 9, Column 1
Self
Row 10, Column 0
Family Member(s)
Row 10, Column 1
Self
Row 11, Column 0
Family Member(s)
Row 11, Column 1
Self
Row 12, Column 0
Family Member(s)
Row 12, Column 1
1 of 13
80
Cardiovascular
Self
Family Member(s)
Hypotension (low blood pressure)
Row 0, Column 0
Row 0, Column 1
Hypertension (high blood pressure)
Row 1, Column 0
Row 1, Column 1
Bradycardia (low pulse)
Row 2, Column 0
Row 2, Column 1
Tachycardia (fast pulse)
Row 3, Column 0
Row 3, Column 1
High Cholesterol
Row 4, Column 0
Row 4, Column 1
Arrhythmia/Abnormal heart rhythm
Row 5, Column 0
Row 5, Column 1
Palpitations
Row 6, Column 0
Row 6, Column 1
Angina/Chest pain
Row 7, Column 0
Row 7, Column 1
Heart attacks
Row 8, Column 0
Row 8, Column 1
Heart murmurs
Row 9, Column 0
Row 9, Column 1
Artificial valve
Row 10, Column 0
Row 10, Column 1
Swelling/Edema
Row 11, Column 0
Row 11, Column 1
Vasovagal Syncope
Row 12, Column 0
Row 12, Column 1
Hypotension (low blood pressure)
Hypertension (high blood pressure)
Bradycardia (low pulse)
Tachycardia (fast pulse)
High Cholesterol
Arrhythmia/Abnormal heart rhythm
Palpitations
Angina/Chest pain
Heart attacks
Heart murmurs
Artificial valve
Swelling/Edema
Vasovagal Syncope
Self
Row 0, Column 0
Family Member(s)
Row 0, Column 1
Self
Row 1, Column 0
Family Member(s)
Row 1, Column 1
Self
Row 2, Column 0
Family Member(s)
Row 2, Column 1
Self
Row 3, Column 0
Family Member(s)
Row 3, Column 1
Self
Row 4, Column 0
Family Member(s)
Row 4, Column 1
Self
Row 5, Column 0
Family Member(s)
Row 5, Column 1
Self
Row 6, Column 0
Family Member(s)
Row 6, Column 1
Self
Row 7, Column 0
Family Member(s)
Row 7, Column 1
Self
Row 8, Column 0
Family Member(s)
Row 8, Column 1
Self
Row 9, Column 0
Family Member(s)
Row 9, Column 1
Self
Row 10, Column 0
Family Member(s)
Row 10, Column 1
Self
Row 11, Column 0
Family Member(s)
Row 11, Column 1
Self
Row 12, Column 0
Family Member(s)
Row 12, Column 1
1 of 13
81
Respiratory
Self
Family Member(s)
Asthma
Row 0, Column 0
Row 0, Column 1
COPD/Emphysema
Row 1, Column 0
Row 1, Column 1
Chronic bronchitis
Row 2, Column 0
Row 2, Column 1
Sleep apnea
Row 3, Column 0
Row 3, Column 1
Multiple pneumonias
Row 4, Column 0
Row 4, Column 1
Lung cancer
Row 5, Column 0
Row 5, Column 1
COVID-19 complications
Row 6, Column 0
Row 6, Column 1
Asthma
COPD/Emphysema
Chronic bronchitis
Sleep apnea
Multiple pneumonias
Lung cancer
COVID-19 complications
Self
Row 0, Column 0
Family Member(s)
Row 0, Column 1
Self
Row 1, Column 0
Family Member(s)
Row 1, Column 1
Self
Row 2, Column 0
Family Member(s)
Row 2, Column 1
Self
Row 3, Column 0
Family Member(s)
Row 3, Column 1
Self
Row 4, Column 0
Family Member(s)
Row 4, Column 1
Self
Row 5, Column 0
Family Member(s)
Row 5, Column 1
Self
Row 6, Column 0
Family Member(s)
Row 6, Column 1
1 of 7
82
Gastrointestinal
Self
Family Member(s)
Reflux/GERD
Row 0, Column 0
Row 0, Column 1
Stomach ulcers
Row 1, Column 0
Row 1, Column 1
Gallbladder disease
Row 2, Column 0
Row 2, Column 1
Chronic diarrhea
Row 3, Column 0
Row 3, Column 1
Chronic constipation
Row 4, Column 0
Row 4, Column 1
Irritable bowel syndrome
Row 5, Column 0
Row 5, Column 1
Diverticulitis
Row 6, Column 0
Row 6, Column 1
Crohn's Disease
Row 7, Column 0
Row 7, Column 1
Ulcerative colitis
Row 8, Column 0
Row 8, Column 1
GI cancer
Row 9, Column 0
Row 9, Column 1
Hepatitis
Row 10, Column 0
Row 10, Column 1
Pancreatitis
Row 11, Column 0
Row 11, Column 1
Reflux/GERD
Stomach ulcers
Gallbladder disease
Chronic diarrhea
Chronic constipation
Irritable bowel syndrome
Diverticulitis
Crohn's Disease
Ulcerative colitis
GI cancer
Hepatitis
Pancreatitis
Self
Row 0, Column 0
Family Member(s)
Row 0, Column 1
Self
Row 1, Column 0
Family Member(s)
Row 1, Column 1
Self
Row 2, Column 0
Family Member(s)
Row 2, Column 1
Self
Row 3, Column 0
Family Member(s)
Row 3, Column 1
Self
Row 4, Column 0
Family Member(s)
Row 4, Column 1
Self
Row 5, Column 0
Family Member(s)
Row 5, Column 1
Self
Row 6, Column 0
Family Member(s)
Row 6, Column 1
Self
Row 7, Column 0
Family Member(s)
Row 7, Column 1
Self
Row 8, Column 0
Family Member(s)
Row 8, Column 1
Self
Row 9, Column 0
Family Member(s)
Row 9, Column 1
Self
Row 10, Column 0
Family Member(s)
Row 10, Column 1
Self
Row 11, Column 0
Family Member(s)
Row 11, Column 1
1 of 12
83
Musculoskeletal
Self
Family Member(s)
General Osteoarthritis
Row 0, Column 0
Row 0, Column 1
Rheumatoid arthritis
Row 1, Column 0
Row 1, Column 1
Chronic back pain
Row 2, Column 0
Row 2, Column 1
Chronic neck pain
Row 3, Column 0
Row 3, Column 1
Degenerative disc disease
Row 4, Column 0
Row 4, Column 1
Osteoporosis
Row 5, Column 0
Row 5, Column 1
Gout
Row 6, Column 0
Row 6, Column 1
Spinal stenosis
Row 7, Column 0
Row 7, Column 1
General Osteoarthritis
Rheumatoid arthritis
Chronic back pain
Chronic neck pain
Degenerative disc disease
Osteoporosis
Gout
Spinal stenosis
Self
Row 0, Column 0
Family Member(s)
Row 0, Column 1
Self
Row 1, Column 0
Family Member(s)
Row 1, Column 1
Self
Row 2, Column 0
Family Member(s)
Row 2, Column 1
Self
Row 3, Column 0
Family Member(s)
Row 3, Column 1
Self
Row 4, Column 0
Family Member(s)
Row 4, Column 1
Self
Row 5, Column 0
Family Member(s)
Row 5, Column 1
Self
Row 6, Column 0
Family Member(s)
Row 6, Column 1
Self
Row 7, Column 0
Family Member(s)
Row 7, Column 1
1 of 8
84
Endocrine
Self
Family Member(s)
Polycystic Ovarian Syndrome (PCOS)
Row 0, Column 0
Row 0, Column 1
Type 1 Diabetes
Row 1, Column 0
Row 1, Column 1
Type 2 Diabetes
Row 2, Column 0
Row 2, Column 1
Hypothyroidism
Row 3, Column 0
Row 3, Column 1
Hyperthyroidism
Row 4, Column 0
Row 4, Column 1
Hashmito's thyroiditis
Row 5, Column 0
Row 5, Column 1
Graves' Disease
Row 6, Column 0
Row 6, Column 1
Cushing's Syndrome
Row 7, Column 0
Row 7, Column 1
Addison's Disease
Row 8, Column 0
Row 8, Column 1
Hyperparathyroidism
Row 9, Column 0
Row 9, Column 1
Hypoparathyroidism
Row 10, Column 0
Row 10, Column 1
Polycystic Ovarian Syndrome (PCOS)
Type 1 Diabetes
Type 2 Diabetes
Hypothyroidism
Hyperthyroidism
Hashmito's thyroiditis
Graves' Disease
Cushing's Syndrome
Addison's Disease
Hyperparathyroidism
Hypoparathyroidism
Self
Row 0, Column 0
Family Member(s)
Row 0, Column 1
Self
Row 1, Column 0
Family Member(s)
Row 1, Column 1
Self
Row 2, Column 0
Family Member(s)
Row 2, Column 1
Self
Row 3, Column 0
Family Member(s)
Row 3, Column 1
Self
Row 4, Column 0
Family Member(s)
Row 4, Column 1
Self
Row 5, Column 0
Family Member(s)
Row 5, Column 1
Self
Row 6, Column 0
Family Member(s)
Row 6, Column 1
Self
Row 7, Column 0
Family Member(s)
Row 7, Column 1
Self
Row 8, Column 0
Family Member(s)
Row 8, Column 1
Self
Row 9, Column 0
Family Member(s)
Row 9, Column 1
Self
Row 10, Column 0
Family Member(s)
Row 10, Column 1
1 of 11
85
OB/GYN
Self
Family Member(s)
Irregular menses
Row 0, Column 0
Row 0, Column 1
Pregnant
Row 1, Column 0
Row 1, Column 1
Planning pregnancy
Row 2, Column 0
Row 2, Column 1
PCOS
Row 3, Column 0
Row 3, Column 1
Perimenopause
Row 4, Column 0
Row 4, Column 1
Postmenopause
Row 5, Column 0
Row 5, Column 1
Breast cancer
Row 6, Column 0
Row 6, Column 1
Ovarian cancer
Row 7, Column 0
Row 7, Column 1
Uterine cancer
Row 8, Column 0
Row 8, Column 1
Irregular menses
Pregnant
Planning pregnancy
PCOS
Perimenopause
Postmenopause
Breast cancer
Ovarian cancer
Uterine cancer
Self
Row 0, Column 0
Family Member(s)
Row 0, Column 1
Self
Row 1, Column 0
Family Member(s)
Row 1, Column 1
Self
Row 2, Column 0
Family Member(s)
Row 2, Column 1
Self
Row 3, Column 0
Family Member(s)
Row 3, Column 1
Self
Row 4, Column 0
Family Member(s)
Row 4, Column 1
Self
Row 5, Column 0
Family Member(s)
Row 5, Column 1
Self
Row 6, Column 0
Family Member(s)
Row 6, Column 1
Self
Row 7, Column 0
Family Member(s)
Row 7, Column 1
Self
Row 8, Column 0
Family Member(s)
Row 8, Column 1
1 of 9
86
Hematologic/Lymphatic
Self
Family Member(s)
Iron deficiency
Row 0, Column 0
Row 0, Column 1
Sickle cell anemia
Row 1, Column 0
Row 1, Column 1
B12 deficiency anemia
Row 2, Column 0
Row 2, Column 1
Thalassemia
Row 3, Column 0
Row 3, Column 1
Blood thinners
Row 4, Column 0
Row 4, Column 1
Clotting disorder
Row 5, Column 0
Row 5, Column 1
Thrombocytopenia (high platelets)
Row 6, Column 0
Row 6, Column 1
Thrombocytopenia (low platelets)
Row 7, Column 0
Row 7, Column 1
Leukemia
Row 8, Column 0
Row 8, Column 1
Iron deficiency
Sickle cell anemia
B12 deficiency anemia
Thalassemia
Blood thinners
Clotting disorder
Thrombocytopenia (high platelets)
Thrombocytopenia (low platelets)
Leukemia
Self
Row 0, Column 0
Family Member(s)
Row 0, Column 1
Self
Row 1, Column 0
Family Member(s)
Row 1, Column 1
Self
Row 2, Column 0
Family Member(s)
Row 2, Column 1
Self
Row 3, Column 0
Family Member(s)
Row 3, Column 1
Self
Row 4, Column 0
Family Member(s)
Row 4, Column 1
Self
Row 5, Column 0
Family Member(s)
Row 5, Column 1
Self
Row 6, Column 0
Family Member(s)
Row 6, Column 1
Self
Row 7, Column 0
Family Member(s)
Row 7, Column 1
Self
Row 8, Column 0
Family Member(s)
Row 8, Column 1
1 of 9
87
Infectious Diseases
Self
Family Member(s)
Complicated STDs
Row 0, Column 0
Row 0, Column 1
Herpes
Row 1, Column 0
Row 1, Column 1
HIV
Row 2, Column 0
Row 2, Column 1
AIDS
Row 3, Column 0
Row 3, Column 1
TB
Row 4, Column 0
Row 4, Column 1
Lyme disease
Row 5, Column 0
Row 5, Column 1
Complicated STDs
Herpes
HIV
AIDS
TB
Lyme disease
Self
Row 0, Column 0
Family Member(s)
Row 0, Column 1
Self
Row 1, Column 0
Family Member(s)
Row 1, Column 1
Self
Row 2, Column 0
Family Member(s)
Row 2, Column 1
Self
Row 3, Column 0
Family Member(s)
Row 3, Column 1
Self
Row 4, Column 0
Family Member(s)
Row 4, Column 1
Self
Row 5, Column 0
Family Member(s)
Row 5, Column 1
1 of 6
88
Renal/Urological
Self
Family Member(s)
Solitary kidney
Row 0, Column 0
Row 0, Column 1
Chronic UTIs
Row 1, Column 0
Row 1, Column 1
Dysuria (pain with urination)
Row 2, Column 0
Row 2, Column 1
Polyuria (increased frequency)
Row 3, Column 0
Row 3, Column 1
Urinary incontinence
Row 4, Column 0
Row 4, Column 1
Kidney stones
Row 5, Column 0
Row 5, Column 1
Kidney cancer
Row 6, Column 0
Row 6, Column 1
Bladder cancer
Row 7, Column 0
Row 7, Column 1
Prostate cancer
Row 8, Column 0
Row 8, Column 1
Solitary kidney
Chronic UTIs
Dysuria (pain with urination)
Polyuria (increased frequency)
Urinary incontinence
Kidney stones
Kidney cancer
Bladder cancer
Prostate cancer
Self
Row 0, Column 0
Family Member(s)
Row 0, Column 1
Self
Row 1, Column 0
Family Member(s)
Row 1, Column 1
Self
Row 2, Column 0
Family Member(s)
Row 2, Column 1
Self
Row 3, Column 0
Family Member(s)
Row 3, Column 1
Self
Row 4, Column 0
Family Member(s)
Row 4, Column 1
Self
Row 5, Column 0
Family Member(s)
Row 5, Column 1
Self
Row 6, Column 0
Family Member(s)
Row 6, Column 1
Self
Row 7, Column 0
Family Member(s)
Row 7, Column 1
Self
Row 8, Column 0
Family Member(s)
Row 8, Column 1
1 of 9
89
Additional Medical Conditions or Past SurgeriesPlease include any additional history that may be relevant.
Please include any medical conditions or surgeries
90
Which best describes your social preferences?* This field is required.
Please Select
Please Select
Strongly prefer my own company and do not wish for it to be any different
Mostly stay to myself but wish for more active social interactions
Generally find it difficult to enjoy or be productive by myself and strongly prefer being around others most of the time
91
Do you or anyone around you feel that you have any of the following "eccentric" beliefs or practices?* This field is required.
Superstitions
Astrology
Crystal healing
Magic
Witchcraft
Voodoo
Sensing the absent/dead
Telepathic communications
Superpowers
Time travel
None of the above
92
What are your hobbies?
93
How often do you exercise?
Please Select
Please Select
Almost never
Once a week
Twice a week
Three or more times a week
Less than 3-4 times a month
94
What type of exercise do you engage in?
Please Select
Please Select
Cardio/running/walking
Weights/strength training
Yoga/stretching
Mix of cardio, strength training, and stretching
95
What is the typical duration of your exercise routine?* This field is required.
Please Select
Please Select
Brief, 15-30 minutes
Moderate, 30-60 minutes
Extended, greater than 1 hour
96
How would you describe your appetite?* This field is required.
Good, I eat 3 meals a day with snacks when possible
Fair, I have noticed a slight change but without any problematic weight gain/loss
Poor, I skip meals because of decreased desire to eat and enjoy food
Very poor, with unintentional weight change of more than 10 lbs in the past 3 months
Impulsive, I have difficulty stopping even when full
97
How would you describe your nutrition?* This field is required.
Good, I eating regularly and healthy meals generally
Fair, I eat inconsistently and frequently indulge in unhealthy food choices
Poor, I skip meals often due to forgetfulness or lack of time
98
Do you or others find your caffeine use to be excessive?* This field is required.
YESNO
99
List all the following types of caffeine you drink on most days. Select all that apply.* This field is required.
Coffee
Espresso
Soda
Tea
Energy drinks
Caffeine supplements
None
100
What best describes you average daily caffeine intake?* This field is required.
Please Select
Please Select
1 drink or less
1-2 drinks
3-4 drinks
4+ drinks
101
When do you drink most of your caffeine?* This field is required.
Please Select
Please Select
Regularly throughout the day
6am to 10am
10am to 2pm
2pm to 6pm
6pm to 10pm
Later than 10pm
102
What are the primary drivers for your caffeine use? Select all that apply.* This field is required.
Helps socializing
Enjoy the taste, smell, or temperature
Lifts spirits/mood
Improves alertness
Enhances concentration
Relieves headaches/pain
None
103
Do you feel that your caffeine usage could be the source of any of the following health risk? Select all that apply.* This field is required.
Withdrawal headaches
General anxiety
Panic attacks
Irritability
Insomnia
Chronic fatigue
Dehydration
Nutritional deficiencies
Tremors
Heart palpitation
Raised heart rate
Raised blood pressure
Nausea
Intestinal discomfort
None
104
Do you or others find your social media use to be excessive?* This field is required.
YESNO
105
What best quantifies your daily social media usage?* This field is required.
Please Select
Please Select
Minimal, 15 minutes or less
Moderate, 15-30 minutes
Moderate, 30-60 minutes
Significant, 60+ minutes
106
What healthy effects does social media have on your life?* This field is required.
Strengthens interpersonal relationships
Supplements learning and networking
Helps stay current with news
Allows for exchange of ideas
Provides stress relief
Enhances self-image
None
107
Do your social media use lead to any of the following undesirable feelings?* This field is required.
Insecurity about being excluded by friends, family, or peers
Fear of missing out on experiences, events, and trends
Irritability in social interactions
Frustration at inability to access social media platforms
Stress from online bullying/trolling/hate speech
Overwhelmed from information overload
Worried about difficulty maintaining privacy
Guilt about degree of social media usage
Insecurity about personal success, attractiveness, or experiences relative to others
None of the above
Other
108
Do you currently own or have access to firearms or other weapons?* This field is required.
YESNO
109
Do you store your firearms to ensure they are securely and safely kept away from unauthorized access, especially when not in use?* This field is required.
YESNO
110
Do you have someone you can trust for temporary safekeeping of firearms if you are ever in a mental crisis?* This field is required.
YESNO
111
Please explain how you secure your firearms and your plan for their safekeeping.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
112
Signature* This field is required.I hereby certify that all the information provided in this form is true, accurate, and complete to the best of my knowledge.
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