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Reason for care

Select date & time

1 Appointment info

2 Prescreener

Reason for care

3 Contact information

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

What kind of care is being sought?

Psychotherapy Medication Other Not sure

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Substance Use Screening

Do you currently use:

Alcohol Marijuana Opioids Cocaine Stimulants Benzodiazepines None

Has Substance use ever

Caused health issues Affected work/school Led to legal problems N/A no substance use

Please select any of the mental health conditions you have been diagnosed with

Depression Anxiety Bipolar PTSD ADHD Schizophrenia/Psychosis None

Have you ever been hospitalized for behavioral health?

If yes please provide details including date, location, duration, and what led to your hospitalization

Limited to 600 characters

Medical and Social Risk Factors

Please check all that apply

Chronic medical illness Chronic pain Legal issues Housing instability Financial stress Caregiver stress Recent loss Trauma history None of the above

Are you currently prescribed/taking any of the following:

Check all that apply

Stimulants/ADHD medication Benzodiazepines/Anxiety Medication Opioids/Pain medications Methadone/Suboxone/Naltrexone (substance use disorder medications) None of the above

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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THE CLIENT PORTAL IS NOT TO BE USED FOR EMERGENCY SITUATIONS. IF YOU OR OTHERS ARE IN IMMEDIATE DANGER OR EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.