Intake Form
  • Schedule A Free Consultation*
  • Format: (000) 000-0000.
  • Are you currently between 18 and 55 years old?*
  • Are you currently employed, or do you have a stable source of income sufficient to cover your daily bills and expenses?*
  • Are you currently prescribed narcotics such as Suboxone, Methadone, or Percocet? (Your controlled substance dispensing history will be reviewed to verify)*
  • Are you looking to start medication for the treatment of anxiety, depression, ADHD, bipolar disorder, or insomnia?*
  • Which of the following mental health conditions has been causing you the most distress?*
  • 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?*
  • 2. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?*
  • 3. How often do you have difficulty unwinding and relaxing when you have time to yourself?*
  • 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?*
  • 5. How often do you put things off until the last minute?*
  • 6. How often do you depend on others to keep your life in order and attend to details?*
  • Please select the symptoms that you have been experiencing over the past 6 months. (Select all that apply)*
  • 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?*
  • Where do you find yourself struggling to concentrate, pay attention, or stay on task?(Select all that apply)*
  • Please select the symptoms that you began experiencing before 12 years of age.(Select all that apply)*

  • Anxiety Test

    Over the last 2 weeks, how often have you been bothered by the following problems?
  • 1. Feeling nervous, anxious, or on edge.*
  • 2. Not being able to stop or control worrying.*
  • 3. Worrying too much about different things.*
  • 4. Trouble relaxing.*
  • 5. Being so restless that it's hard to sit still.*
  • 6. Becoming easily annoyed or irritable.*
  • 7. Feeling afraid as if something awful might happen.*
  • 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?*
  • Which of the following symptoms have you been experiencing for the past 6 months? (Select all that apply)*
  • Are some of these symptoms present for at least 4 days per week?*
  • Where do you typically find yourself feeling anxious or nervous? (Select all that apply)*

  • 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.*
  • 2. Feeling down, depressed, or hopeless.*
  • 3. Trouble falling or staying asleep, or sleeping too much.*
  • 4. Feeling tired or having little energy.*
  • 5. Poor appetite or overeating.*
  • 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down.*
  • 7. Trouble concentrating on things, such as reading the newspaper or watching television.*
  • 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.*
  • 9. Thoughts that you would be better off dead or of hurting yourself in some way.*
  • 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?*
  • How did you hear about us?*

  • 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. 
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