Language English (US) New Client Pre-Screening Form Enhanced Edge, LLC Client Name * First Name Last Name Client Date of Birth * - Month - Day Year Contact Email * example@example.com Contact Phone Number * Please enter a valid phone number. Home Address * Street Address Street Address Line 2 City State / Province Postal / Zip Code Back Next Save General Information Reason for wanting to schedule with us? * ADHD / ADD Anxiety (GAD) PTSD Depression Substance / Alcohol abuse OCD Personality Disorders Mood Disorders Learning Disabilities Development Disabilities Behavioral Issues (ODD) Autism / Aspergers Disorder Traumatic Brain Injury Peak Performance General Curiousity Athletic Performance Other Please explain: * What is your occupation? Any additional hobbies? (helps us with treatment plan building) What services are you interested in? * QEEG Brain Mapping Neurofeedback Biofeedback Alpha-Stim I am looking to: * Please Select Get more information Schedule an appointment Ask questions Have you been seen at a mental health office in the last 12 months? * Yes No If yes, where did you receive those services? Are you currently on any Medications? * Yes No If yes, what medications and who prescribes these medications? Back Next Save Additional Questions / Information Were you professionally referred to our office? * Yes No If yes, who were you referred by? How did you hear about us? * Please Select Friend / Family Google Search Email Social Media Web Search Advertisement Signage Professional Referral Mental Edge Counseling Website Other How would you like us to contact you regarding this form? * Phone Call Email Either Please list your availability for a phone call regarding this form: List general availability or specific dates/times Do you have any outstanding questions for the Enhanced Edge team? Any other information you would like to include? Save Submit Should be Empty:
