Patient Intake Questionnaire

Start Your Confidential Assessment

Please complete the short form below so our clinical team can better understand your needs.

Depression Anxiety Bipolar Depression PTSD Suicidal Thoughts Others (Please Specify)

Antidepressants Therapy / Counseling TMS Other treatments No prior treatment

Yes No

If yes, please list medications

Are you experiencing active suicidal thoughts right now?

Yes No

If yes, please seek immediate medical attention

Do you have insurance coverage?

Yes No

Your information is kept strictly confidential and reviewed only by licensed healthcare professionals.

Braxia is a company of tomorrow, focused on psychedelic medicine for advanced mental health treatments.