Please enable JavaScript in your browser to complete this form. - Step 1 of 41To start, tell us why you are seeking help. (click all that apply) *General Anxiety or PanicStress At Work Or SchoolI'm Feeling DepressedI'm Struggling With AddictionI'm Having Trouble SleepingTrauma (Past or Present)Something ElseNextWhat services are you interested in? *Individual TherapyGroup TherapyPsychiatry (Medication Management)All the abovePreviousNextDo you have a history of Suicide Attempts? *YesNoHow many SA have you had in your lifetime? *When was your last Suicide Attempt?What was the result in your last SA? (example, hospitalization, ICU, etc.) PreviousNextHow often do you feel afraid something awful might happen? *Not At AllSeveral Days A WeekMore Than Half The TimeNearly EverydayPreviousNextHow often do you become easily annoyed or irritable? *Not At AllSeveral Days A WeekMore Than Half The TimeNearly EverydayPreviousNextHow often are you not able to control or stop worrying? *Not At AllSeveral Days A WeekMore Than Half The TimeNearly EverydayPreviousNextHow often do you have trouble falling asleep, staying asleep, or sleeping too much? *Not At AllSeveral Days A WeekMore Than Half The TimeNearly EverydayPreviousNextHow often are you feeling tired or having low energy? *Not At AllSeveral Days A WeekMore Than Half The TimeNearly EverydayPreviousNextDo you have any history of trauma? (Emotional, Sexual, or Physical) *YesNoCan you further elaborate on your reported history of trauma? (Emotional, sexual, physical) *PreviousNextDo you have any history of being sexually or financially exploited? *YesNoPlease Explain *PreviousNextHave you ever put yourself or someone else in harms way as a result of your mental health symptoms? *YesNoPlease explain: *PreviousNextDo you have any history of substance abuse? (Drugs or Alcohol) *YesNoLast date of use and what substance or Drug of choice? *Please explain in more detail: *Do you have a history of overdosing? *YesNoPlease describe when this occured, the substances used, and what happened after *Are you currently engaged in AA/NA or other sober support networks? *YesNoHave there been negative consequences due to your substance use? *YesNoPlease explain in more detail: *PreviousNextAre you currently experiencing any withdrawal symptoms? *YesNoPlease select any current withdrawal symptoms you are experiencing *NauseaTremorsBodyAchesRestless LegsExcessive YawningRunny NoseDiarrheaAbdominal CrampsVomitingSweatsChillsAgitationIncreased AppetiteConstipationPoor AppetiteGI ComplaintsDizzinessRestlessnessHeadachesAnxiosnessUnsteady GaitHypersensitivity to lightHypersensitivity to NoiseMusic/Body achesOther - Not ListedAdditional Symptoms not listed? *PreviousNextAre you open to trying anti craving medications? *YesNoDo you have a history of using MAT/anti-craving medications? *YesNoHow long were you on this medication and when were you prescribed? When did you stop taking this medication? *PreviousNextHave you been hospitalized in the past year? *YesNoWhat are the dates of your hospitalization? *Was your visit voluntary or involuntary? *VoluntaryInvoluntaryWhat was the name of the hospital, the reason for the visit, & the outcome? *PreviousNextAre you currently working with any outpatient provider (Psychiatrist, psychologist, therapist, etc.) *YesNoName of the provider *How long have you been working with this provider? *PreviousNextAre you currently taking any prescribed medications? *YesNoWhat medications are you currently taking, how many times per day, and what dosage? *Will you need us to provide these medications? *YesNoPreviousNextDo you have any history of eating disorders? *YesNoPlease briefly describe what eating disorders you are/were struggling with? *Were the eating disorders ever diagnosed by a physician? *YesNoPreviousNextDo you have any active diagnosis? *YesNoWhat were the diagnosis, what year were you diagnosed, & who was the diagnosing physician? *PreviousNextWill you need assistance with Disability, FMLA, SSI? *YesNoPreviousNextAre you currently employed? *YesNoJob position type? *Full timePart timeWhat is your current work schedule? *How long have you been employed and in what position? *Are you at risk for losing employment? *YesNoExplain why? *PreviousNextAre you at least 18 years of age? *YesNoWhat is your highest level of education? *Are you currently enrolled as a student? *YesNoAny issues with school? *YesNoPlease describe *Have you ever been placed on academic suspension or expelled? *YesNoDetails (Incident that resulted in suspension or expulsion) *Onset (When did this occur) *Duration (How long did this last, is it still ongoing)? *Who is your guardian? *What grade are you in? *PreviousNextAre you currently in any learning assistance programs? (IEP 504, etc...) *YesNoN/APreviousNextAre you currently under the care of a physician for pain management? *YesNoPreviousNextHow often do you have trouble relaxing? *Not At AllSeveral Days A WeekMore Than Half The TimeNearly EverydayPreviousNextHow often are you so restless that it is hard to sit still? *Not At AllSeveral Days A WeekMore Than Half The TimeNearly EverydayPreviousNextHow often do you have trouble concentrating on things, such as reading or watching television? *Not At AllSeveral Days A WeekMore Than Half The TimeNearly EverydayPreviousNextHow often do you have little interest or pleasure in doing things? *Not At AllSeveral Days A WeekMore Than Half The TimeNearly EverydayPreviousNextHow often do you feel down, depressed, or hopeless *Not At AllSeveral Days A WeekMore Than Half The TimeNearly EverydayPreviousNextHow often do you have thoughts that you would be better off dead, or of hurting yourself? *Not At AllSeveral Days A WeekMore Than Half The TimeNearly EverydayPreviousNextOf your previous answers, how difficult have these issues made It for you to do your work, take care of things at home, or get along with other people? *Not Difficult At AllSomewhat DifficultVery DifficultExtremely DifficultPreviousNextPlease click all the following that apply to you *Thoughts Of Harming MyselfThoughts Of Harming OthersPrevious Suicide AttemptsHallucinations, Delusions, ParanoiaHistory Of Harming AnimalsSubstance Use (Drugs or Alcohol)Currently Diagnosed With Mental Health DisordersUrgent Medical NeedsHistory of SeizuresDifficulty With Day-To-Day TasksDifficulties From Physical PainPlans To Commit Suicide In PlacePreviousNextDo you require technology needs? Examples: Hearing Aids Visual Aids Physical Other *YesNoList below *PreviousNextDo you require assistance to communicate, read, or write in English? *YesNoPreviousNextDo you have the means and ability to complete a Telehealth program? *YesNoPreviousNextHow do you intend to cover the cost of treatment? *Insurance (Check My Coverage)Pay Out-of-PocketI'm Not SurePlease name your Insurance ProviderYour Insurance Member IDPreviousNextHow Did You Hear About Us? *Friend or Family MembersTreatment Center or CompanySchoolHospital or FacilityTherapist or DoctorOnlineOtherTreatment Center or Company NameSchool NameHospital or Facility NameTherapist or Doctor's OfficeOtherPreviousNextWhere are you completing this form? *HomeHospitalResidential ProgramOtherPreviousNextWhere do you currently reside? *On ownFamily Members HomeSober Living EnvironmentOtherWho do you currently reside with? *SelfImmediate FamilyExtended FamilyFriendsRoommateUnhousedOtherName of current treatment center?What level of care are you currently in? *RTCPHPIOPNot SurePreviousNextWhat is your gender? *MaleFemaleTrans (Male to Female)Trans (Female to Male)Non-BinaryGender Non-ConformingOther Not ListedPreviousNextName *FirstLastDate of Birth *Phone Number *Email *AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSubmit