Pre-Screening Survey

First Name

Last Name

Preferred Personal Pronouns Please Select She/Her He/Him They/Them Ze/Hir Other

Date of Birth

Preferred Method of Contact Please Select Email Phone

Phone Number

Email Address

Street Address

City

State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Are you planning on using insurance? If yes, please let us know which insurance provider you plan on using Please Select BCBS United UMR UBH Optum HealthChoice

Are you currently (or in the last 30 days) experiencing any of the following? Please check all that apply. Addiction Alcohol use Anxiety Attention issues Avoidance Bullying Body image issues Chronic pain/illness Depression Disordered eating Dissociation Feeling worthless Grief/loss Guilt Hallucinations Hopelessness Hyperactivity Issues Impulsive Irritable/ Angry Life transitions Low self-esteem/self-worth Nightmares No Motivation Obsessive-thoughts Panic attacks Parent/child estrangement Phobias/fears Posttraumatic stress disorder Relationship Issues Sadness Shame Self-harming behaviors Sexual identity/expression Sleep difficulties Social anxiety Stress Suicidal thoughts Trauma Trust Issues

Reasons for Seeking Services

Have you been in therapy before? If so, please tell us your likes/dislikes about your previous experience below.

Do you have a preferred therapist in mind? Please Select Ashley Lewis Hayley Brown Jenny Vanfield Desiree Smith Sarah West

Would you like in person sessions or virtual? Please Select In Person Virtual