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* 1. What is your age?

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* 2. In what city do you live?

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* 3. What is your profession?

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* 4. How many hours do you work or go to school per week?

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* 5. How would you prefer to meet with your psychiatrist?

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* 6. Which three of the following words would you use to describe your ideal psychiatrist? Please only mark three boxes.

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* 7. How did you hear about Dr. Goldman?

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* 8. In the last 12 months, how many times did you visit a mental health provider?

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* 9. Do you have any other comments, questions, or concerns?

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