Initial Pre-Assessment Please enable JavaScript in your browser to complete this form. - Step 1 of 21To 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 Every DayPreviousNextHow Often Are You Feeling Tired or Having Low Energy? *Not At AllSeveral Days a WeekMore Than Half The TimeNearly EverydayPreviousNextHow 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 DifficultPreviousNextHow Often Do You Feel Bad About Yourself? - Feelings of Failure Or That You Have Let Your Friends And Family Down *Not At AllSeveral Days A WeekMore Than Half The TimeNearly EverydayPreviousNextPlease Click All The Following That Apply To YouThoughts Of Harming MyselfThoughts Of Harming OthersPrevious Suicide AttemptsHallucinations, Delusions, ParanoiaHistory Of Aggression Like Domestic ViolenceHistory 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 PlacePlease Select All That ApplyPreviousNextWhat Is Your Gender? *MaleFemaleTrans (Male to Female)Trans (Female to Male)Non-BinaryGender Non-ConformingOther Not ListedPlease Provide Your GenderPreviousNextHow 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 OfficeOtherPreviousNextHow do you intend to cover the cost of treatment? *Insurance (Check My Coverage)Pay Out-of-PocketI'm Not SurePlease name your Insurance Provider *Your Insurance Member ID *PreviousNextName *FirstLastPhone *Email *Which state do you live in? *Date of Birth *Submit