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What is the reason for seeking care?

Anxiety Depression Trauma (Sexual, physical, emotional, childhood abuse) Relationship issues Substance use Grief Stress Other

Have you had mental health treatment in the past? Which level of care?

Inpatient/Hospitalization Residential Partial Hospitalization (PHP)/Day Treatment Intensive Outpatient (IOP) Outpatient therapy I have not had mental health treatment in the past.

What mental health concerns have occurred in the past?

Taking psychiatric medication now Taken psychiatric medication in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

What are your goals for treatment? What do you want to work on?

Limited to 600 characters

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