Pathways Application

1

Which antidepressant(s) are you currently taking, and at what dose?* This field is required.

2

How long have you been on this medication?* This field is required.

Less than 6 months

6 to 12 months

More than 12 months

3

Are you currently taking any other prescribed medications, supplements, or substances?* This field is required.

YESNO

4

What else are you currently taking?* This field is required.

5

Do you have any concerns with your use of alcohol or recreational substances?* This field is required.

YESNO

6

Which substances and how often do you use them?* This field is required.

7

In the past month, have you experienced thoughts of self-harm or suicide, or made any plans to harm yourself?* This field is required.

YESNO

8

Are you currently prescribed medication for Bipolar Disorder or Schizophrenia?* This field is required.

YESNO

9

How would you describe your current symptoms of depression or anxiety?* This field is required.

Stable for several months

Fluctuating but manageable

Severe or worsening

10

Are you currently experiencing significant stress, relationship conflict, bereavement, or major life changes?* This field is required.

YESNO

11

What are you experiencing?* This field is required.

12

What is your postcode (for arranging pharmacy)?* This field is required.

13

By providing your name and email address you consent to being contacted by our team.* This field is required.www.peridotclinic.com/privacy-policy/

First Name

Last Name

14

Email* This field is required.

example@example.com