Anxiety Intake Questionnaire Name * First Name Last Name Email * Date of Birth * MM DD YYYY Age * For how long have you been suffering from Anxiety? What triggers your Anxiety? What are the factors you are aware of... Are there any proven methods which help when your Anxiety is triggered? Have you ever consulted a Medical Doctor or Psychologist for your condition? Have you been diagnosed with a specific condition(s)? Do you currently take any medication, or natural supplement, for Anxiety? What are you looking to achieve by working with me? Do you have any specific goals? Thank you! I look forward to working with you, and helping you,Heather M. Rowe, CHC
