Your Story

Please take a few minutes to answer the questions in the form below.

Be as honest and thorough as you can, and then on our call we can go into more detail.

All your answers are submitted securely and kept private and confidential. You can request your records at any time and we can remove all your data upon your request.

I use the answers you give me to problem solve your situation and determine the best solution. In many cases, there are a number of different options, and we will be able to discuss those together.

Complete the Questionnaire Before Your Appointment

Step 1 of 9

  • This form is submitted according to the terms, privacy, and medical disclaimer policies of this site. Anything you enter is held in the strictest confidence and will not be disclosed to anyone else. You can request a copy of all information you have submitted for your medical record. Please answer as honestly as you can. Let's get started!

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