Please state your relationship status and number of children if applicable.

Please state what you do for a living or what you do during the majority of your days (ie, work, school, teach, projects...)

Please list any conditions you are currently dealing with, whether or not they've been diagnosed by a medical doctor.

Please list any past diagnosed conditions, surgeries, and/or reasons for major treatments.

For the purposes of this question, Marijuana is considered a drug.

Do you feel or have you ever felt addicted to anything (drug, alcohol, food...)?

How cared for, supported and comforted do you feel by those around you?

What do you drink on a daily/regular basis?  Check all that apply.

Please provide set time or range if that applies.

Please provide set time or range if that applies.

Please add anything else you'd like to share with me before we meet.

Referred by a friend, Yelp, Google, facebook...

Your answers will be sent to me in a private email.  No one else will review/see your input here.