Name *

First Name

Last Name

What's your phone number? *

(###)

###

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Are you completing this form on behalf of a client? *

If you're not the client, then please select "No." If you're filling this out on behalf of a client, please select "Yes" and complete the rest of this form as if it were your own.

Yes, I am filling this out on behalf of a client.

No, I am the client.

Are you a minor or an adult? *

Minor

Adult

Are you insured? *

If you are completing this form on behalf of a client, please let us know if the client has insurance.

Yes

No

I do not know.

Can you afford to pay for therapy out of pocket if you are not insured? *

Yes

No

I am not sure

In the past 30 days, have you had any thoughts of hurting yourself or others?. *

We are here to help and will not judge you.

Yes

No

I prefer not to say

What have you experienced within the last 3 months?

Aggression or anger

Anxiety

Difficulty getting out of bed

Excessive energy or hyperactivity

Grief or bereavement

Guilt or persistent self-blame

Feelings of hopelessness

Loneliness or isolation

Loss of interest in activities previously enjoyed

Panic attacks or sudden overwhelming fear

Paranoia or irrational distrust

Physical trauma or injury

Engaging in self-harm or self-injury

Are you taking any current medications? *

Yes

No, and I've never been prescribed a medicine.

No, but I've been prescribed medicines in the past.

What's your current living situation? *

My current housing is adequate.

My current housing is inadequate.

I'm currently homeless.

Have you ever served in the military? *

Yes

No

Are you currently employed? *

If you're employed full or part time, or if you are self-employed, please select "Yes."

Yes

No

I'm in and out of work.

Have you ever been incarcerated? *

Your answer to this question won't disqualify you from treatment.

Yes

No