Intensive Treatment Application
Please fill out the following questionnaire as completely as possible.
Please describe how anxiety is affecting you.
What is your motivation for seeking treatment at this point in your life?
Are you currently on prescribed medication. If yes, please specify the name, dosage, and length of time.
Have you ever been diagnosed with another disorder?
Do you have the time, energy, and finances if accepted into the intensive therapy program?
Please let us know how to contact you.
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