Intake Form

Please complete the form below. Feel free to paste your results from the Reichian Personality Quiz into the final box if you wish.

If there are problems with the online version, please download this version, complete it and email it to me at devaraj227@gmail.com. Thank you.

Name *

First

Last

Email *

Phone *

Gender *

Nationality *

Age *

Height *

Weight *

Do you smoke? If so, how much please? *

Do you drink alcohol? If so, please let me know how much weekly. *

Do you use recreational drugs? If so, please let me know which ones and how much. (This information is confidential). *

Have you ever been diagnosed with a psychiatric condition, including depression, anxiety or drug or alcohol dependence? If yes, please give me more details including how long ago. *

Are you currently using any prescription or mood-altering medications? If yes, please give details including dosage. *

Do you have any significant physical limitations, from injuries, operations or similar? If yes, please give me details. *

Please let me know your reason, or what is motivating you, to do therapeutic work

Use this space to give me some more background psychological information about yourself. You may include the scores from the Reichian Personality Test if you wish (optional).

Hi, I’m Devaraj