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What is the reason you are seeking therapy at this time?

Briefly list symptoms or concerns, for example: Anxiety, Depression, Bipolar Disorder, Adjustment to College, etc.

Limited to 600 characters

What kind of care is being sought?

Psychotherapy Assessment and letter for surgery Other Not sure

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

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