SAMAA

Personal Information

First Name

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Surname

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Birthday

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Country

Language Spoken

Phone

Gender

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Have you been diagnosed with any of the following mental health conditions? (Select all that apply)

Have you ever received therapy or counseling before?

Have you experienced any of the following symptoms in the past 6 months? (Select all that apply)

Are you currently taking any medications for mental health conditions?

Have you ever been diagnosed with any neurological conditions? (Select all that apply)

Do you have a history of substance use or addiction?

Have you experienced any major life events or traumas that may impact your mental health? (Select all that apply)

Do you have any chronic physical health conditions?

Terms & Conditions