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IOP Pre Questionnaire
Please answer the following questions and a clinician will reach out to you for the next steps upon completion
* Indicates required question
Email
*
Your email
Name:
*
Your answer
Phone Number
*
Your answer
Referred by
*
Your answer
Are you currently in Therapy for OCD?
*
Yes
No
Are you using Exposure and Response Prevention?
*
Yes
No
Have you been hospitalized or sought a higher level of care?
*
Yes
No
If yes to the above question, please share where, when, and what you sought help for:
Your answer
Are you currently doing trauma treatment?
*
Yes
No
Will you willing to sign an ROI for us to talk to your therapist?
*
Yes
No
Have you felt effective in your current treatment?
*
Yes
No
Why do you believe you have or have not been successful?
*
Your answer
Do you experience auditory or visual hallucinations?
*
Yes
No
Are you currently taking any psychoactive medications?
*
Yes
No
If yes to the above question, which medications do you take?
Your answer
How comfortable are you in sitting in front of a computer for 2-3 hour treatments?
*
Not Comfortable At All
1
2
3
4
5
Completely Comfortable
Will you require family support or coaching?
*
Yes
No
Please indicate what type of family support you would like to have?
*
General information about the treatment you are receiving
Pre-treatment Psychoeducation Session for your Family (30 Mins.)
Post Treatment Education Session for your Family (30 Mins.)
Coaching for your family to fully understand ERP and how to support you (Additional Fees apply)
Required
Do you have the ability to pay for treatment $1,995
*
Yes
No
Do you agree that you will be an active participant in group through out the program?
*
Yes
No
I don't know, I thought this was a class
Will you need a financial plan?
*
Yes
No
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