What type of therapy are you looking for?
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What is bringing you to therapy at this time? You don't need to give your full history here. A few sentences about what has been going on and what you would like help with is enough.
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What would you most like to be different as a result of therapy?
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Have you participated in therapy before? If yes, is there anything you already know works well, or does not work well, for you in therapy?
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Are you currently working with another therapist or mental health provider? If yes, please briefly describe the type of treatment you are currently receiving:
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Are you currently receiving, or have you recently been recommended for, a higher level of mental health care such as an intensive outpatient program (IOP), partial hospitalization program (PHP), residential treatment, or inpatient treatment? If yes, please briefly explain:
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Have you had a psychiatric hospitalization, emergency psychiatric evaluation, or mental health crisis requiring emergency care within the past 6 months? If yes, please briefly explain:
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Are you currently experiencing thoughts of suicide or thoughts of seriously harming yourself or someone else?
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Is there anything happening right now that makes you concerned about your immediate safety or someone else's safety? If yes, please briefly explain:
This appointment request form is not monitored as a crisis service. If you are in immediate danger or experiencing a mental health emergency, call 911 or go to the nearest emergency department. You may also call or text 988 for the Suicide & Crisis Lifeline.
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Please provide the name and phone number of an emergency contact or trusted person who could be contacted if there were a serious safety emergency during telehealth treatment.
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