Your Name (required)
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Is it okay to leave voicemail at this number?
Is it okay to send texts to this number?
Your Email (required)
Is it okay to send emails to this address?
Insurance Provider & ID Number
Amount of Co-pay (if known)
College Counseling CenterPrimary Care PhysicianInternet SearchFamily or FriendLIKEMIND websiteOther
MarriedIn a Committed RelationshipDating CasuallySingleDivorcedSeparatedWidowedOther
Full-TimePart-TimeFull-Time StudentPart-Time StudentUnemployedOther
Relationship to you
Emergency Contact Phone Number
What are the problem(s) for which you are seeking help?
When did you first notice these problems?
Within the last monthWithin the last six monthsWithin the last yearOver the last few yearsDuring adolescenceDuring childhood
What are your goals for treatment?
What mental health services are you interested in?
Individual PsychotherapyMedication ConsultationGroup TherapyNeuropsychological EvalCouples TherapyADHD EvaluationLearning DisordersOther
Current Symptoms (Check all that apply)
Depressed moodAppetite ChangesMind RacingAnxiety/WorryIrritabilitySuspicious of othersPanic AttacksFatigueSchool/Work ProblemsSleep ProblemsFeelings of GuiltFinancial StressCan't Enjoy ActivitiesRelational ProblemsPoor ConcentrationImpulsive BehaviorOthers
Any thoughts/feelings of wanting to hurt or kill yourself (past or present)?Yes, In the PastYes, CurrentlyNo
Any current or past self-injurious behavior (cutting, burning, etc.)?
Have you received mental health services in the past? (Check all that apply)
PsychotherapyMedication ManagementGroup TherapyOutpatientInpatientPsychiatricOtherNone
Name of provider/facility, Location of treatment, Approximate dates of treatment & Reason for treatment
Personal and Family Medical/Mental Health History