Gift Of Therapy

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Gift Of Therapy

Behind The Smiles - The Darius Roberts Foundation Inc.

"We respect your privacy and will ensure that any information you share with us is kept confidential and not used for any other purposes."

First and Last Name: *

Email Address: *

DOB: *

YYYY

City and State *

How would you prefer to be contacted? *

Phone

Text

Required

Please provide the phone number where you would like to be contacted. *

Please note that we are not licensed clinicians. This is Pre-screening form and the individual completing this form must be the interested party.

If this an emergency, stop completing this form and contact local emergency services 911.

Why are you seeking therapy?

To manage a mental health condition such as depression, anxiety or PTSD

To address a specific issue or challenge in your life such as relationship problems or work stress

To improve your overall well-being and personal growth

Other:

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Have you had suicidal ideation, thoughts, or attempts within the last 12 months?

Yes

Clear selection

Do you or are currently seeing a therapist, counselor or psychiatrist ?

Yes

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Have you received therapy before?

Yes, I have received therapy before and found it helpful

Yes, I have received therapy before but it did not work for me

No, I have never received therapy before

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If you answered Yes, I have received therapy before but it did not work for me. Please state what didn't work for you

Do you currently have health insurance?

Yes

Clear selection

Submit

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