Please enable JavaScript in your browser to complete this form.Name *FirstLastDate *Email *Therapist *Haleigh KauffmannUyen DinhMaria ChaseShannon SmithKirsten ColeTaylor KrachtBrittany PreslarAaron YearwoodMarina SkrabalakRebecca WojciechowskiFrequency of symptoms in the past 48 hours. Selected Value: 0Intensity of symptoms from 1-10 with 10 being the worst. Selected Value: 0Duration of symptoms in minutes. *510203060Which symptom are you identifying. *AnxietyDepressionEmotional RegulationGeneral StressDaily average amount of sleep you have gotten in hours. *678910Daily average screen time this week i.e. phone, video games, YouTube in hours. *024 68Daily average amount of exercise you have gotten in hours. *01020304560Submit
