Anxiety Self-Referral Form
Please complete this form to help us understand your experience with anxiety and determine how we can best support you.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Please Select
Male
Female
Non-binary
Prefer not to say
Other
How long have you been experiencing symptoms of anxiety?
*
Please Select
Less than 1 month
1-6 months
6-12 months
More than 1 year
Have you previously received support for anxiety?
*
Yes
No
Please rate the severity of your anxiety symptoms over the past two weeks.
*
Not severe
1
2
3
4
5
6
7
8
9
Extremely severe
10
1 is Not severe, 10 is Extremely severe
How often have you felt nervous, anxious, or on edge in the past two weeks?
*
Not at all
Several days
More than half the days
Nearly every day
In the past two weeks, how often have you been unable to stop or control worrying?
*
Not at all
Several days
More than half the days
Nearly every day
How much have your anxiety symptoms interfered with your daily life (work, school, relationships, etc.)?
*
Not at all
0
1
2
3
4
5
6
7
8
9
A great deal
10
0 is Not at all, 10 is A great deal
Do you have any current thoughts of self-harm or harming others? (If yes, please seek immediate help or contact emergency services.)
*
No
Yes
Please describe any additional information you feel is important for us to know about your anxiety or situation.
Submit Self-Referral
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