Screening

SCREENING QUESTIONS

Please read these questions and fill out to the best of your ability. I you believe or if another provider has suggested any of the conditions below, then Dr. Muir will not be the best fit for you clinical needs. If the answer to any of the questions below are "yes," please do not proceed. Refer back to your referral source for another more appropriate provider. Please answer these questions truthfully. Thank you.

* Indicates required field

Do you Medicaid or Medicare as a secondary insurance? *

Do you need an evaluation for disability, FMLA or a disability extension? *

Do you need an assessment or treatment for ADD/ADHD or what you may believe to be any attention deficit disorder? *

Are you younger than 25 or older than 64 years old? *

Have drugs or alchol ever been a source of conflict in any of your relationships in the last 6 months? *

Have you ever (past or present) binged, purged, restricted food or exercised excessively to lose or prevent weight gain? *

Have you ever been treated for, diagnosed with, told by friends or family or believe that you may have a personality disorder? *

Have you been discharge from an inpatient psychiatric hospital or an intensive outpatient care program within the last month? *

Do you have any ongoing pain issues that require treatment with pain medications? *

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