Reality Co. Retreat Intake Form

Name *

First Name

Last Name

Phone *

(###)

###

####

Have you ever received any mental health services? *

Choose any that apply.

Counseling/therapist/psychologist

Intensive Retreat (For Example: OnSite)

Rehabilitation/Treatment Center

None

Mental Health History *

Check any that apply currently or historically.

Depression

Trouble Sleeping

Trouble Concentrating

Low Energy/Drive

Self Harm

Suicidal Thoughts

PTSD

Anxiety

Anxiety Attacks

Addiction

Obsessive Compulsive Disorder

Excessive Guilt

Shame

Lonely

Nightmares