Is this evaluation for yourself or for someone else? *
What is the first and last name of the person being evaluated? *
What is your phone number? *
We don't accept insurance for evaluations however feel free to complete this section if you would like us to check your out of network benefits
Insurance carrier name
Member ID #
What is the patient's date of birth? (we use this information to check your benefits)
Name and date of birth of primary subscriber
What are you currently struggling with? *
What are your goal(s) for this evaluation? *
Have you been previously diagnosed with a mental health condition by a professional? If yes, please list all previous diagnoses *
Is this your first time being evaluated? *
If your previous answer was no, please indicate which type of evaluation you have recieved in the past and the outcome.
Is there anything else that you would like us to know?
Please note that our clinicians are not crisis counselors. We encourage all clients to call 911 or go to their nearest emergency room if you are having a mental health crisis. Thank you for your time, we will be in touch shortly.
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