Intake Form                            

                  your edge
      is about to
               get started
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Welcome,

We look forward to helping you Unlock your Edge! Please take a moment and complete the MEFS Intake Form to assist us with customizing your program. The more information provided, the better we can assist you with reaching your mental fitness goals.

Completion time: 2–5 minutes.

Personal Information

Gender
Ethnicity

Relationship Status

Student / Employment Status

Athletic / Sports

Do you play sports?

Physician Information

Symptoms / Treatment

Do you have any diagnosed medical or mental health conditions?
Are you being treated by a medical professional for the above conditions?
Are you currently experiencing any physical pain or discomfort?
Are you being treated by a professional for the physical pain or discomfort?
Are there any health-related conditions, concerns or questions that you wish to discuss?

Injury Specific Information

(if applicable)
Are your injuries related to an accident?

Medical Problems

Surgical Procedures (Last 10 Years)

Allergies

Current Medications Prescribed for Pain, Sleep Disturbance, Mental Health Conditions, Etc.

MEFS Programs and Services

What other mind-body services have you received currently or in the past?

Contact Information

Allow Mail?
Allow messages?
Allow messages?
Allow messages?
Allow Emails?
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