Testimonials

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Questionaire

Do you have a history of any of the following?

 Seizure Disorder Stroke Head Injury Brain Tumor Cancer NONE

Please let us know which of the following symptoms you’ve experienced:
 Having a lack of emotion Problems paying attention Jumping between unrelated topics Problems expressing ideas Feeling anxious or angry Hearing/seeing things that aren't there False beliefs that are not based on reality NONE

Have you been treated for Schizophrenia before?
 Yes No

Are you currently receiving treatment for Schizophrenia?
 Yes No

Are you over 18?
 Yes No

How did you hear about us?
 TV Radio Referral Flyer/Brochure Internet Search Web Advertisement Facebook Previous Patient

Name (First and Last):

Phone:

Email Address:

Are you a resident of Washington State?

Zip Code:

What is the best time to contact you?

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