Intake Form

Schedule A Free Consultation*
First Name*
Last Name*
Phone Number*
Please enter a valid phone number.
Birth Date*

MonthDayYear
Please select the Florida county you currently live in. If your county is not listed below, our services are not available in your area. *
Are you currently between 18 and 55 years old?*

YesNo
Are you currently employed, or do you have a stable source of income sufficient to cover your daily bills and expenses?*

YesNo
What is your current occupation?*
Are you currently prescribed narcotics such as Suboxone, Methadone, or Percocet? (Your controlled substance dispensing history will be reviewed to verify)*

YesNo
Are you looking to start medication for the treatment of anxiety, depression, ADHD, bipolar disorder, or insomnia?*

YesNo
Which of the following mental health conditions has been causing you the most distress?*

AnxietyDepressionBipolar DisorderADHDInsomnia
Please describe the symptoms you have been experiencing in as much detail as possible.*

0/0
We are unable to proceed

Thank you for your interest. However, several requirements must be met to begin treatment. You must be between the ages of 18 and 55 and currently reside in one of the following counties: Broward, Collier, Duval, Hillsborough, Lee, Martin, Miami-Dade, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, or Seminole. Additionally, you cannot currently be prescribed narcotics, such as Suboxone, Methadone, or Percocet. Lastly, we do not offer talk therapy.
ADHD Test

Please answer the questions below, rating yourself on each of the criteria listed. As you answer each question, select the option that best describes how you have felt and conducted yourself over the past 6 months.
1. How often do you have difficulty concentrating on what people are saying to you even when they are speaking to you directly?*

NeverRarelySometimesOftenVery Often
2. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?*

NeverRarelySometimesOftenVery Often
3. How often do you have difficulty unwinding and relaxing when you have time to yourself?*

NeverRarelySometimesOftenVery Often
4. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to before they can finish them themselves?*

NeverRarelySometimesOftenVery Often
5. How often do you put things off until the last minute?*

NeverRarelySometimesOftenVery Often
6. How often do you depend on others to keep your life in order and attend to details?*

NeverRarelySometimesOftenVery Often
ADHD Test Score
Please select the symptoms that you have been experiencing over the past 6 months. (Select all that apply)*

Lacking attention to detailDifficulty focusingTrouble listeningFailing to complete tasksPoor organizational skillsAvoiding tasks requiring focusLosing important thingsDistracted easilyForgetfulnessNone of the above
ADHD Symptoms
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or pay attention during conversations with others?*

Not difficult at allSomewhat difficultVery difficultExtremely difficult
Where do you find yourself struggling to concentrate, pay attention, or stay on task?(Select all that apply)*

At workAt schoolAt homeWith friends or relativesNone of the above
Please select the symptoms that you began experiencing before 12 years of age.(Select all that apply)*

Lacking attention to detailDifficulty focusingTrouble listeningFailing to complete tasksPoor organizational skillsAvoiding tasks requiring focusLosing important thingsDistracted easilyForgetfulnessNone of the above
ADHD Symptoms before 12 years of age
Anxiety Test

Over the last 2 weeks, how often have you been bothered by the following problems?
1. Feeling nervous, anxious, or on edge.*

Not at allSeveral daysOver half the daysNearly every day
2. Not being able to stop or control worrying.*

Not at allSeveral daysOver half the daysNearly every day
3. Worrying too much about different things.*

Not at allSeveral daysOver half the daysNearly every day
4. Trouble relaxing.*

Not at allSeveral daysOver half the daysNearly every day
5. Being so restless that it's hard to sit still.*

Not at allSeveral daysOver half the daysNearly every day
6. Becoming easily annoyed or irritable.*

Not at allSeveral daysOver half the daysNearly every day
7. Feeling afraid as if something awful might happen.*

Not at allSeveral daysOver half the daysNearly every day
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?*

Not difficult at allSomewhat difficultVery DifficultExtremely difficult
Which of the following symptoms have you been experiencing for the past 6 months? (Select all that apply)*

RestlessnessEasily FatiguedDifficulty ConcentratingIrritabilityMuscle TensionDifficulty SleepingNone of the above
Anxiety Symptoms
Are some of these symptoms present for at least 4 days per week?*

YesNo
Where do you typically find yourself feeling anxious or nervous? (Select all that apply)*

At workAt schoolAt homeWith friends and familyNone of the above
Anxiety Test Score
Depression Test

Over the last 2 weeks, how often have you been bothered by any of the following?
1. Little interest or pleasure in doing things.*

Not at allSeveral daysMore than half the daysNearly every day
2. Feeling down, depressed, or hopeless.*

Not at allSeveral daysMore than half the daysNearly every day
3. Trouble falling or staying asleep, or sleeping too much.*

Not at allSeveral daysMore than half the daysNearly every day
4. Feeling tired or having little energy.*

Not at allSeveral daysMore than half the daysNearly every day
5. Poor appetite or overeating.*

Not at allSeveral daysMore than half the daysNearly every day
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down.*

Not at allSeveral daysMore than half the daysNearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television.*

Not at allSeveral daysMore than half the daysNearly every day
8. Moving or speaking so slowly that other people could have noticed. Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual.*

Not at allSeveral daysMore than half the daysNearly every day
9. Thoughts that you would be better off dead or of hurting yourself in some way.*

Not at allSeveral daysMore than half the daysNearly every day
If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*

Not difficult at allSomewhat difficultVery DifficultExtremely difficult
Depression Test Score
How did you hear about us?*

InstagramGoogleReferred by a friendOther
Controlled Substance Disclaimer

We are licensed to prescribe stimulants for the treatment of ADHD and benzodiazepines for the treatment of generalized anxiety disorder, when clinically appropriate. However, these medications CANNOT be prescribed together. We cannot prescribe stimulants if you are currently taking benzodiazepines, and we cannot prescribe benzodiazepines if you are currently taking stimulants. Your controlled substance dispensing history will be reviewed to verify.
Please Upload A Valid Driver's License Photo *

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ADHD Test

Anxiety Test

Depression Test

Controlled Substance Disclaimer