Required Field
Please note: An email will be sent from The Coleman Institute to the above address/addresses which will include sensitive information.
Other Drug Use (Previous and Current):
Physician / Psychiatrist / Therapist Info:
Past Medical History (Select all that apply):
Current Psychiatric Problems (Please rate on a scale of 1 to 10 with 10 being the most severe)
Past Psychiatric Problems:
Upbringing
Did you witness or suffer from any abuse?
Below is a list of common symptoms associated with benzo dependency. Please rate each symptom below on a scale of 0-4 (0 means you do not have the symptom at all and 4 means you have the symptom and it’s severe).
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