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If you wish to retain the services of Dr Harleen Kopski, please fill out the following form, and sign up here.

Name: 
Age: 
Sex: 
Housing Assignment: 
Previous Diagnoses:
Current/Past Medical Conditions:
Medication: 
Emergency Contact: 
Can we share information with your emergency contact:

Are you currently suffering from any of the following symptoms, and how often do you suffer from them? ( 	Usually, Often, Sometimes, Rarely, Never)
Pounding heart			
Sweating:					
Trembling or shaking					
Shortness of breath					
Afraid or scared					
Chest pain or discomfort					
Nausea or abdominal distress					
Feeling dizzy or unsteady					
Fear of losing control or going crazy		
Numbness or tingling sensations	
Chills or hot flashes					
Fear of dying					
Constant or persistent worry					
Feeling of choking					
Unable to relax					
Feeling of being unreal					
Nervous					
Feeling shaky or wobbly					
Irritable or difficulty sleeping					
Trembling hands					
Avoid situations because of anxiety				
Feeling lightheaded or faint

Please indicate whether or not these symptoms: 
Interfere with work:
Affect my relationships with friends or family:
Have led to using alcohol to get by:
Have led to using drugs:

Over the last two weeks, have you noticed the following: (Use the number that best describes you.)

0 - NOT AT ALL
1 - RARELY
2 - SOMETIMES
3 - OFTEN
4 - MOST OF THE TIME

I feel sad, down in the dumps or unhappy: 
I can’t concentrate or focus:
Nothing seems to give me much pleasure:
I feel tired; have no energy:
I have had thoughts of suicide:
Changes in sleeping patterns: (more, less)
Changes in appetite: (more, less) 
I worry about dying or losing control:
I am nervous or shaky in social situations:
I have nightmares or flashbacks:
I am jumpy or feel startled easily:
I avoid places that strongly remind me of a bad experience:
I can’t get certain thoughts out of my mind:
I feel I must repeat certain acts or rituals:
I feel the need to check and recheck things:

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Harley Quinn

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