Balanced Mind - Intake Questionnaire
Please note, your responses to the questions below are 100% confidential and will not be shared with ANYONE. I will use the information you provide to guide our next conversation to see if the Balanced Mind: Antidepressant Tapering Support program is a good fit for you. There are no right or wrong answers. Your openness and honesty is greatly appreciated!
Email address *
Name *
Your answer
City, State/Province *
Your answer
Please provide a brief description of your history of medication use as it pertains to your mental/emotional health. Use specific drug names and dosages whenever possible. *
Your answer
Describe your attempts, if any, at withdrawing from antidepressants in the past. *
Your answer
I have discussed my desire to withdraw from my antidepressant with my prescribing healthcare professional.
I am ready to experience life without the use of an antidepressant. *
Not at all
Yes, that's so me!
The side effects of my antidepressant are a problem for me. *
Not at all
Yes, that's so me!
I am willing to make time for myself every week to prepare for a safe, effective taper. *
Not at all
Yes, that's so me!
I’m scared to find out who I am without antidepressants. *
Not at all
Yes, that's so me!
I have a strong self-care practice currently in place. *
Not at all
Yes, that's so me!
I have a strong social support system in place. *
Not at all
Yes, that's so me!
I can imagine a future version of myself that is thriving. *
Not at all
Yes, that's so me!
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