Loading...
Initial Assessment
Please enable JavaScript in your browser to complete this form.
Start
press
Enter
Please enable JavaScript in your browser to complete this form.
Name
*
First
Middle
Last
Cell Phone
*
Email
*
Email
Confirm Email
Prefered Day / Time Preference
*
Please tell me the days and time ranges that you would prefer.
Examples: Thursdays @ 6:00 PM or Tuesdays, Wednesdays, Fridays 4-8PM
Insurance Provider
Cigna
Anthem
Husky/Medicaid
None/Cash
Safety Questions
*
Psychiatric Hospitalization
Suicide Attempt
Illegal Substance Use
Self-Harm
Aggressive or Violent Outbursts
None of the above
Please check all that apply
When was your last Hospitalization?
Within last 6 months
At least 6-12 months
More than a year ago
When was your last Suicide Attempt?
Within last 6 months
At least 6-12 months
More than a year ago
What substances do you use?
*
Marijuana/Alcohol
Molly/Ecstasy/Lean
Cocaine/Crack/Heroin
Other
How often do you use?
*
Few Times a Month or Less
Few Times a Week or Less
Daily
There is not a time I am not using.
Please describe your Aggressive/Violent Outburst below:
Reasons for seeking help.
*
Anxiety
Depression
Substance Use
School/Peer Conflict
Low Self Esteem
Life / Family Changes (Divorce, Recent Move, etc)
Transitioning to Higher Education (Heading from Primary to Secondary Schools, or heading to College)
Life Skills (Getting job, Leaving Home, Social Skills, Time Management, Life Balance)
Other
Please check all that apply.
Reason for Seeking Help - Other
Submit
