Name *

First Name

Last Name

Phone

(###)

###

####

Have you been diagnosed with Major Depressive Disorder?

Yes

No

Not Sure

How long have you struggled with depression?

Less than 1 year

1-3 years

3-5 years

5 or more years

Are you currently taking one or more anti-depressant medications?

Yes

No

Not Sure

Do you find yourself wishing you could find more relief than your current anti-depressant medication?

Yes

No

Not Sure

Do the side effects from your anti-depressant medication outweigh the benefits?

Yes

No

Not Sure

No Medication

How many different anti-depressant medications have you tried in the past?

0

1

2

3

4

5 or more

When is the best time to contact you?

Morning

Afternoons

Evening

As Soon As Possible

Are you currently a patient at Align Health Services or Koithan PC?

Yes

No