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.

very long term (>3 years)

long term (1-3 years)

intermediate term (6-12 months)

Short term (1-6 months)

3

What is your past experience of antidepressant withdrawal?* This field is required.

very severe

severe

mild to moderate

none/unknown

4

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

YESNO

5

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

6

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

YESNO

7

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

8

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

9

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

YESNO

10

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

11

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

YESNO

12

What are you experiencing?* This field is required.

13

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

14

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

15

Date of Birth* This field is required.

Date

16

Email* This field is required.

example@example.com

17

Phone Number* This field is required.

Please enter a valid phone number.

18

Would you like to receive Peridot Clinic’s newsletter with updates on mental health resources? You can unsubscribe at any time.

YESNO