Hylane Follow-UP Questionnaire

Note: We provide high-level care and are a fee-for-service practice. We do not accept any insurance plans.

Name*
First Last
Email*
Phone
1. Task Management
Rate your ability to organize and follow through on tasks in your current condition:
- Unable to do so
- Sometimes can
- Frequently able
- Able to all the time
2. Living Situation
Number of people you live with:
Their relationship to you:
3. Local Support
Do you have extended family nearby who can actively help you?
- Yes
- No
4. Self-Destructive Behaviors
Have you engaged in self-destructive behaviors (e.g., self-harm, anorexia, substance abuse)? Please elaborate:

1. Task Management