Dream or reality

Happy patients only

Neuropsychiatric Clinic

Thinking of you!

Bogdan Mikhailuk

Don't put your dream aside! Make it true!

Intake Assessment

Intake Assessment Form

Do we have permission to leave a voicemail?

WHAT INSURANCE COVERAGE do you have?*

WHAT IS YOUR AGE or the AGE of the minor you would like to be seen?

What are your primary reasons for seeking help?*

Hallucinations?

How long have you been suffering with this problem?

Have you been receiving treatment for these mental health issues?

HAVE YOU RECEIVED A FORMAL DIAGNOSIS of a Mental or substance disorder?

Are you currently seeing a mental health professional for this problem?

How long have you been receiving treatment?

Are you on psychiatric medication currently?*

Are you taking any medication for pain?

Have you been hospitalized?

Do you use any substances?*

Alcohol?*

HAVE YOU BEEN TREATED WITH 2 OR MORE ANTIDEPRESSANTS in the past?

DO YOU HAVE A HISTORY OF SEIZURES or DIAGNOSIS OF EPILEPSY?

Do you have any magnetic materials surgically implanted above your shoulders?

How severe on a scale of one to 10 do you feel your symptoms are?*

How do you feel like these symptoms are impairing your life?

WOULD YOU CONSIDER TRANSCRANIAL MAGNETIC STIMULATION IF you have failed multiple antidepressants?

What areas of your live are being impaired?*

none mild moderate severe
Work
Family
Social
School