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Tell us a little bit about what prompted you to reach out and what you’re hoping to achieve in therapy?

Example: My friends noticed I'm not my usual self and I'm looking for a therapist to help with symptoms of stress and anxiety.

Limited to 600 characters

Are you currently seeing a provider? Have you seen one in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Do you take any medications for mental health purposes? Who manages those for you?

Limited to 600 characters

Do you now or have you ever engaged in self-harm?

Yes No Unsure

Are you currently or have you ever thought about or attempted to kill yourself?

Yes, I am currently struggling with suicidal intensity Yes, I thought about suicide in the past but have never attempted suicide Yes, I attempted suicide in the past No, I have never thought about suicide Unsure

Are you currently struggling with urges to kill or hurt someone else? Have you ever had those urges or acted on them before?

Yes, I am currently struggling with urges to kill or hurt someone else. Yes, I have struggled with urges to kill or hurt someone else in the past and I did not act on it. Yes, I have struggled with urges to kill or hurt someone else in the past and I acted on it. No, I have not had urges to kill or hurt someone else in the past. Unsure

Is there any verbal, physical, or emotional violence in your relationships?

If yes, please describe.

Limited to 600 characters

Tell me about your current substance use or any addictive behaviors you engage in (what substance/behavior, how much, how often).

Include prescription medications not used as prescribed as well as recreational substances, gambling, shopping, etc.

Limited to 600 characters

Have you ever been treated for an addiction?

If yes, please describe (when, where, for what, what was the treatment outcome).

Limited to 600 characters

Are you currently or do you expect to be involved in a legal proceeding? Check all that apply.

Court case Divorce Child Custody dispute Lawsuit against an employer Lawsuit for an accident? I do not expect to be involved in any legal proceedings.

Are you currently or do you expect to be involved in a workers’ compensation claim?

Yes, I am currently involved in a worker's compensation claim. I anticipate being involved in a worker's compensation claim. No, I am not involved in nor do I anticipate being involved in a worker's compensation claim.

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