What's your name? *

First Name

Last Name

What's your phone number? *

(###)

###

####

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 you were the client.

Yes, I'm 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're filling this out on behalf of a client, please let us know if the client is insured.

Yes

No

I'm not sure.

In the last 30 days have you had any thoughts of wanting to harm yourself or others? *

Yes

No

I'd rather not say

What have you experienced within the last 3 months? *

Please select all that apply.

Aggression or anger

Anxiety

Difficulty getting out of bed

Excessive energy

Grief

Guilt

Hopelessness

Loneliness

Loss of interest

Panic attacks

Paranoia

Physical trauma

Self-harm or self-mutiliation

Sexual trauma

Substance or drug abuse

Suicidal thoughts

Worry

Worthlessness

Other

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