Mental Health Check-Up | New Zen Clinic

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First Name

Last Name

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Do you have health benifits

Check off all systems you have been experiencing

Unable to enjoy activities

Sleep pattern disturbance

Loss of interest

Change in appetite

Excessive guilt

Racing thoughts

Crying spells

Excessive worry

Anxiety attacks

Suicidal thoughts

Intense Fear

Grief

PTSD

Sleep disorder

ADHD

Migraines

Memory loss

Substance misuse

Body aches

Detachment/dissociation

Irritability

Have you been commited

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Are you looking to get in and see someone right away ? When are you available?

If you checked off 2+ choices you need to booking an Mental Health Assessment with us!

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