Client Self-Screening Form
Answer the questions to determine whether to proceed or stop sharing details. Note that we do NOT store any of your private medical information.
Are you under the age of 21?
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Yes
No
I have a personal history of psychosis, psychotic episodes, schizophrenia, or schizoaffective disorder (whether formally diagnosed or not).
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Yes
No
I have a Bipolar I disorder diagnosis with a history of mania.
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Yes
No
I have a first-degree family history of schizophrenia or Bipolar I (parent, sibling, or child).
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Yes
No
I have an active seizure disorder or history of unprovoked seizures without neurology clearance.
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Yes
No
I have an active, untreated substance use disorder (alcohol, stimulant, or opioid).
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Yes
No
I have uncontrolled cardiovascular disease (severe hypertension, recent cardiac event, unstable angina, uncontrolled arrhythmia).
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Yes
No
I have taken Lithium in any form in the last 30 days.
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Yes
No
I am currently experiencing thoughts of harming myself or others.
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Yes
No
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