Intensive Treatment Application
Please fill out the following questionnaire as completely as possible.
Please describe how anxiety is affecting you.
Your answer
What is your motivation for seeking treatment at this point in your life?
Your answer
Are you currently on prescribed medication. If yes, please specify the name, dosage, and length of time.
Your answer
Have you ever been diagnosed with another disorder?
Your answer
Do you have the time, energy, and finances if accepted into the intensive therapy program?
Your answer
Email *
Please let us know how to contact you.
Your answer
Name *
Your answer
Phone *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.