Eligibility Form

Eligibility Check

Are you over 21 years old?

Yes No

Eligibility Check

Do you suffer from a medical condition where conventional medication or treatment is not working for you? This can include things like Physio or Therapy.

Yes No

What condition are you applying for?

Please select all that apply.

Pain Sleep Mental Health A mixture of conditions

Prescription Check

I have been prescribed a medication or tried therapy for pain, sleep or mental health
(This can be a current or past prescription.) I have never been prescribed a medication.

Psychiatric & Medical History

Have you ever been:

Sectioned under the Mental Health Act Referred to Community Mental Health Team None

Have you ever been diagnosed with any of these mental health conditions?

Auditory or Visual Hallucinations Bipolar Disorder / Manic Depression / Mania Cyclothymia EUPD (Emotionally Unstable Personality Disorder) Major Depressive Disorder Paranoia Psychosis Schizophrenia None

Have you ever suffered from any of these physical conditions?

Autoimmune Hepatitis DVT (Deep Vein Thrombosis) Heart Attack Hepatitis C Liver Cirrhosis NEAD (Non-Epileptic Attack Disorder) Renal Failure Transplant (previous or planned) None

Have you had suicidal thoughts in the past 2 years?

Yes No

Have you had a suicide attempt in the past 5 years?

Yes No

Pregnancy Check

Are you pregnant?

Yes No Not Applicable

Personal Information

Date of Birth

Address & Gender

Gender: Male Female

Medical History Self Declared

Please list current prescriptions and over-the-counter supplements (incl. any CBD oils/products):

Consent & Submit

Preferred Contact Methods:

Email Phone SMS

I confirm that the information provided is true and accurate.