Welcome To Elocin!
Please complete these 12 questions and we will reach out as soon as possible.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Primary Care Physician
First Name
Last Name
Current Therapist / Counselor
First Name
Last Name
Therapist's Phone Number
Please list the problem(s) which you are seeking help?
Current Symptoms
*
Depressed mood
Racing thoughts
Excessive worry
Unable to enjoy activities
Impulsivity
Anxiety attacks
Sleep pattern disturbance
Increase risky behavior
Avoidance
Loss of interest
Increased libido
Hallucinations
Concentration/forgetfulness
Decrease need for sleep
Suspiciousness
Change in appetite
Excessive energy
Excessive guilt
Increased irritability
Fatigue
Crying spells
Decreased libido
Other
Have you ever had feelings or thoughts that you didn't want to live?
*
Yes
No
Do you currently feel that you don't want to live?
Yes
No
Exercise Level
Do you exercise regularly?
Yes
No
How much time each day do you exercise?
How many caffeinated beverages do you drink a day?
Substance History
Have you ever smoke? Or do you currently smoke?
Yes
No
Check if you have ever tried the following
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy
Other
How many packs per day?
How many years?
Personal History
Are you currently:
Working
Student
Unemployed
Disabled
Retired
Are you currently:
Married
Partnered
Divorced
Single
Widowed
Do you have any children?
Yes
No
Please list ages and gender:
*
Have you ever been arrested?
Yes
No
Additional information
Emergency Contact
First Name
Last Name
Phone Number
Date
-
Month
-
Day
Year
Date
Signature
Guardian Signature (if under age 18)
Submit
Submit
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