Skip to content 
Your intake questionnaire, made simple.
Complete your questionnaire before your first appointment so Jeffrey can better understand your goals, concerns, and the support you are looking for.
Before you begin
- Set aside a few quiet minutes
- Answer as completely as you feel comfortable
- Read the General Information page at the end
- Save a copy before returning the form
Helpful tip: If your browser does not save typed answers reliably, download the PDF to your device before completing it.
A clear three-step process
Choose the method that works best for you. The same fillable PDF can be completed digitally or printed and filled out by hand.
1. Open or download
Open the fillable questionnaire in a new tab, or download the PDF directly to your device.
2. Complete and save
Type into the fillable fields or print the form and write your responses clearly by hand.
3. Return before your visit
Save a completed copy, then return it using the method discussed for your appointment.
Complete it digitally
Open the PDF, enter your responses in the fillable fields, and save a completed copy to your device before closing the file.
- Works best when downloaded first
- Review every page before saving
- Keep a copy for your records
Prefer pen and paper?
Download and print the questionnaire, complete it legibly by hand, and bring or return it as arranged before your appointment.
- Print all questionnaire pages
- Use dark ink and write clearly
- Read the final information page
A note about personal information
The questionnaire may include personal or health information. Use care when emailing attachments. If you have privacy concerns—or are unsure how to return your completed form—please call before sending it.
This questionnaire is not for emergencies. If you are experiencing an urgent or life-threatening situation, contact local emergency services.
Questions first?
Jeffrey can clarify the process before you share or send your completed questionnaire.
Ready to complete your intake?
Open the fillable questionnaire, review every page, and save a completed copy before returning it.
