What kind of treatment do you need?

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Please fill out this form to determine what level of treatment is appropriate for you

Email *

What is your name? *

Date of birth? *

YYYY

Please provide your phone number: *

What is your insurance? *

Are you having difficulty managing your responsibilities (work, household etc.)? *

Yes

Are you experiencing difficulty sleeping or staying asleep? *

Yes

Are you sleeping excessively or feeling fatigued all the time? *

Yes

Do you feel a lack of interest or withdrawal from activities you previously enjoyed? *

Yes

Are you experiencing conflicts or issues with family members or loved ones? *

Yes

Do you feel withdrawn, isolated, or have difficulty connecting socially with others? *

Yes

Are you engaging in behaviors like (e.g., substances, impulsive actions) *

Yes

Do you have thoughts that are concerning to you? *

Yes

Have you been thinking about or expressing feelings of hopelessness, worthlessness, or suicide? *

Yes

Have you been self-harming or engaging in dangerous behaviors (e.g., cutting, reckless behavior)? *

Yes

Do you have a high level of irritability or feel easily frustrated? *

Yes

Do you have difficulty focusing or concentrating on tasks? *

Yes

Scoring

2 or more “Yes” responses may indicate the need for therapy and/or medication management.
3 or more “Yes” responses may indicate the need for Intensive Outpatient Programming (IOP).
An indication of “Yes” on questions 7, 8, or 9 requires evaluation for intensive services.

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