Daya
Mental Health & Wellness

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New Client Questionnaire

Please Submit For New Patient Appointments

First Name

Last Name

Phone

What concerns would you like to be seen for? ? What symptoms/ concerns are you having?

List ALL medications and doses you are currently taking

Do you currently have an issues with drug or alcohol use?

Have you been hospitalized in the last 12 months?

No

Yes

Are you interested in therapy or medication management? Or both? Do you have a provider preference?

How did you find us? Were you referred from someone/ somewhere?

Please allow one business day for a return call

Thanks for submitting!

(828) 412-3330
(828) 778-2973