Mental Health Application Process

Home
Our Treatments
Our Approaches
About
Resources
- Mental Health Assessments
- Blog

Home
Our Treatments
Our Approaches
About
Resources
- Mental Health Assessments
- Blog

866-833-1822

Get Started

Home
About
- Who We Are
- Our Staff
Our Treatments
Our Approaches
Resources
- Blog
- Mental Health Assessments
Get Started

Home
About
- Who We Are
- Our Staff
Our Treatments
Our Approaches
Resources
- Blog
- Mental Health Assessments
Get Started

Mission Connection Healthcare

- Step 1 of 21

To Start, Tell Us Why You Are Seeking Help. (Click All That Apply)

General Anxiety or Panic
Stress At Work Or School
I'm Feeling Depressed
I'm Struggling With Addiction
I'm Having Trouble Sleeping
Trauma (Past or Present)
Something Else

What Services Are You Interested In? *

Individual Therapy
Group Therapy
Psychiatry (Medication Management)
All the above

Do you have a history of Suicide Attempts? *

How 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.)

How Often Do You Feel Afraid Something Awful Might Happen? *

Not At All
Several Days A Week
More Than Half The Time
Nearly Everyday

How Often Do You Become Easily Annoyed Or Irritable? *

Not At All
Several Days A Week
More Than Half The Time
Nearly Everyday

How Often Are You Not Able To Control Or Stop Worrying? *

Not At All
Several Days A Week
More Than Half The Time
Nearly Everyday

How Often Do You Have Trouble Falling Asleep, Staying Asleep, or Sleeping Too Much? *

Not at all
Several Days a Week
More Than Half The Time
Nearly Every Day

How Often Are You Feeling Tired or Having Low Energy? *

Not At All
Several Days a Week
More Than Half The Time
Nearly Everyday

How Often Do You Have Trouble Relaxing? *

Not At All
Several Days A Week
More Than Half The Time
Nearly Everyday

How Often Are You So Restless That It Is Hard To Sit Still? *

Not At All
Several Days A Week
More Than Half The Time
Nearly Everyday

How Often Do You Have Trouble Concentrating on Things, Such As Reading or Watching Television? *

Not At All
Several Days A Week
More Than Half The Time
Nearly Everyday

How Often Do You Have Little Interest or Pleasure in Doing Things? *

Not At All
Several Days A Week
More Than Half The Time
Nearly Everyday

How Often Do You Feel Down, Depressed, or Hopeless? *

Not At All
Several Days A Week
More Than Half The Time
Nearly Everyday

How Often Do You Have Thoughts That You Would Be Better Off Dead, Or Of Hurting Yourself?

Not At All
Several Days A Week
More Than Half The Time
Nearly Everyday

Of 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 All
Somewhat Difficult
Very Difficult
Extremely Difficult

How Often Do You Feel Bad About Yourself? - Feelings of Failure Or That You Have Let Your Friends And Family Down *

Not At All
Several Days A Week
More Than Half The Time
Nearly Everyday

Please Click All The Following That Apply To You

Thoughts Of Harming Myself
Thoughts Of Harming Others
Previous Suicide Attempts
Hallucinations, Delusions, Paranoia
History Of Aggression Like Domestic Violence
History Of Harming Animals
Substance Use (Drugs or Alcohol)
Currently Diagnosed With Mental Health Disorders
Urgent Medical Needs
History of Seizures
Difficulty With Day-To-Day Tasks
Difficulties From Physical Pain
Plans To Commit Suicide In Place

Please Select All That Apply

What Is Your Gender? *

Male
Female
Trans (Male to Female)
Trans (Female to Male)
Non-Binary
Gender Non-Conforming
Other Not Listed

Please Provide Your Gender

How Did You Hear About Us?

Friend or Family Members
Treatment Center or Company
School
Hospital or Facility
Therapist or Doctor
Online
Other

Treatment Center or Company Name

School Name

Hospital or Facility Name

Therapist or Doctor's Office

Other

How do you intend to cover the cost of treatment? *

Insurance (Check My Coverage)
Pay Out-of-Pocket
I'm Not Sure

Please name your Insurance Provider *

Your Insurance Member ID *

Name *

First

Last

Phone *

Email *

Which state do you live in? *

Date of Birth *

If you or someone you know is in a crisis or in danger – These Resources can provide you with immediate help.

Get Immediate Help Now

National Domestic Violence Hotline: 1-800-799-7233

National Suicide Prevention Lifeline: 1-800-273-TALK (8255)

National Hopeline Network: 1-800-SUICIDE (800-784-2433)

Crisis Text Line: Text “DESERVE” TO 741-741

Self-Harm Hotline: 1-800-DONT CUT (1-800-366-8288)

American Association of Poison Control Centers: 1-800-222-1222

National Crisis Line – Anorexia and Bulimia: 1-800-233-4357

GLBT Hotline: 1-888-843-4564

TREVOR Crisis Hotline: 1-866-488-7386

Get Immediate Help Now

CERTIFIED BY: