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What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Stress and life changes Other

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

Add some details associated with the reason for seeking care

E.g., triggers, recent issues, how long have symptoms been present, etc.

If you selected "Other" under the first question, please explain:

If this does not apply to you, just enter "N/A"

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