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The First Visit
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February 27, 2016
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Treatment
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This request is not an emergency, or urgent matter - I wish to proceed
Name
*
First
Last
Email
*
Phone
*
Please tell us the basics about the person for whom treatment is being requested
Age
*
Under 18
18-24
25-34
35-44
45-54
55-64
65 or Above
Prefer Not to Answer
Sex
*
Male
Female
Prefer Not to Answer
Reason treatment is being sought
*
How were you referred to Dr. Flynn?
*
What are the main issues, check all that apply:
*
Depression
Bipolar Disorder/Manic Depression
Eating Issues
Addiction/drug dependence
Anxiety/Panic
Focus and concentration
Insomnia
Autoimmune issues
Pain
Anger/irritability
Low energy/brain fog
Other, please specify below
Other
Check all of the following that are applicable:
*
In therapy now
On psychiatric medication now
In the hospital now or recently
In therapy in the past
Taken psychiatric medication in the past
Attempted suicide in the past
Hospitalized for psychiatric reasons in the past
Known neurologic or genetic disorder
None of the above
What kind of care is being sought?
*
Medication
Psychotherapy (counseling/talk therapy)
Both
Nutritional/brain optimization etc
Walsh Protocols
Not sure
Other - please specify
Other
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