Hello! If you’ve been impacted by accutane, I deeply sympathize and honor your desire to recover your health. Please fill out this intake form with the following considerations in mind:
For any answers longer than one word, please type your answer in a separate document and then copy them into this form. (This is more easily done if you use a laptop or desktop computer.) This is so that if something goes wrong with the form submission, you won’t lose your answers.
Please be as detailed as possible in your answers.
If you don’t feel comfortable answering a particular question, that’s ok. Just type “prefer not to answer.”
Note that any behavior(s) that you may feel embarrassed about likely has to do with neurotransmitters. Knowing about your behaviors can help us identify which neurotransmitters you may be deficient in. While dealing with accutane damage, I suffered from severe, suicidal depression and compulsive behaviors as my system tried desperately to regulate itself.
After you complete this form, you will be asked to sign a client information letter, client agreement, and consent for treatment form. All these are necessary before I can work with you.