*

First Name

Last Name

Are you currently dealing with any mental health symptoms that affect your daily life? *

(Examples: anxiety, sadness, sleep issues, low motivation, etc.)

NO

YES

Do you have a history of mental health conditions like PTSD or Bipolar Disorder? *

NO

YES

Do you ever see or hear things others don’t? *

NO

YES

Do you ever think about harming yourself or others? *

NO

YES

Do you use any substances (alcohol, marijuana, etc.)? *

NO

YES

Have you ever been in therapy before? *

NO

YES