Halaxy - Patient Details

Patient Details

* Patient

Patient Details Contacts Addresses

* Medicare * Courage to Connect consent form

* More Information

Payment Personal questions

* Inventory of Interpersonal problems * Adverse Chidhood Experience (ACE) Questionnaire * Dissociative Experiences Scale (DES) 2 International Trauma Questionnaire - (ITQ) Young Schema Questionnaire - (YSQ-R) SMI - Schema Mode Inventory v1.1 * ASQ-SF - Attachment Style Questionnaire - Short Form * ECR-S - Experiences in Close Relationships Scale DASS 21 * Mark Completed

Patient

Thank you for deciding to participate in the Courage to Connect group program!

A screening process is required to ensure this program will be beneficial for you. Can you please complete this online intake form. If your results indicate any concerns, Rachael will contact you to discuss.

Patient Details

* Name

Title

* First Name

Middle Name

Surname

Preferred Name

Date of Birth

Gender

Contact Email

Timezone

Phone Numbers

Add New Phone

Introduction Source

Can you please indicate how you found out about this program.

* Introduction Source

* Mandatory questions