Hylane Follow-UP Questionnaire - The Whole Psychiatry & Brain Recovery Center

Name*

First Last

Email*

Phone*

City & State of Residence*

What is your age?*

Please list your top five symptoms:*

Do you enjoy competitive activities?*

On a scale of 1 to 5, with 5 being the most ambitious, how ambitious are you?*

On a scale of 1 to 5, with 5 being the most disciplined, how disciplined are you?*

Physician fees are out of pocket, and they do not participate in any insurance plans including medicare or medicaid. Is this workable for you?*

There are usually specialty tests whose fees are directly payable to the laboratory, which are not covered by insurance, is this acceptable?*

Are you free of substance use such as alcohol or recreational drugs?*

Rate your ability to organize and follow through on tasks in your current condition:

Number of people you live with:

Their relationship to you:

Do you have extended family nearby who can actively help you?

Eating healthy meals daily:

Finding good doctors/care:

Help with tasks you're unable to do (e.g., shopping, cleaning):

Describe any emotional, physical, sexual trauma, or stress you experienced in the first 10-15 years of your life:

Have you engaged in self-destructive behaviors (e.g., self-harm, anorexia, substance abuse)? Please elaborate:

What will you do if/when you get well?

Are you ever afraid of getting well? Please explain:

How were you referred to us:*

Message*

1. Task Management