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What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

What kind of care is being sought?

Psychotherapy Medication (Our office can only refer out) Other

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

Tell us about what is going on and what brought you here?

Please give us a detailed synopsis so we can make sure we can place you with the right fit.

Limited to 600 characters

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