Psychological Appointment Pre-Screening
Please complete this form to help us understand your needs and prepare for your upcoming appointment.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name and Phone Number
*
Preferred Appointment Date & Time
*
What brings you to seek psychological support at this time? (Briefly describe your main concern)
*
Please indicate any current symptoms or concerns you are experiencing:
*
Anxiety
Depression
Stress
Sleep problems
Relationship issues
Grief or loss
Other
Have you previously attended therapy or counseling?
*
Yes
No
Please rate the level of distress you are currently experiencing:
*
None
1
2
3
4
5
6
7
8
9
Extreme
10
1 is None, 10 is Extreme
In the past month, have you had thoughts of harming yourself or others?
*
Yes
No
Please indicate any relevant medical or psychological history:
Submit Pre-Screening Form
Should be Empty: