What kind of treatment plan are you trying to make?

What kind of treatment plan are you trying to make?*

Mental Health Treatment Plan

Aesthetic Treatment Plan

Who are you seeking services for?

Who are you seeking services for?*

Which of the following best describes you?

Which of the following best describes you?*

17 or Younger

18-24 Years Old

25-29 Years Old

30-39 Years Old

40-49 Years Old

50-59 Years Old

60-69 Years Old

70+ Years Old

As a minor* I need help and I’ve talked with my parent about this.

* A person under the age of 18 years old.

As a minor* I need help and I’ve talked with my parent about this.*

I acknowledge that I have spoken with my parent(s) and have their permission to complete this form.

What types of challenges do you face?

Select all that apply

What types of challenges do you face? Select All that apply.*

Have you ever been diagnosed with a mental health issue?

Have you ever been diagnosed with a mental health issue?*

Yes

To your knowledge, which of the following mental health conditions have you been diagnosed with?

Select all that apply.

To your knowledge, which of the following mental health conditions have you been diagnosed with?*

ADHD

PTSD

Depression

Anxiety

Bipolar Disorder

Schizophrenia

Something Else

Have you previously sought help managing the mental health issue before?

Have you previously sought help managing the mental health issue before?*

Yes

What best describes how the mental health issue began?

What best describes how the mental health issue began?*

Gradual over time

Triggered by a specific event

Following a traumatic experience

Sudden onset without a clear cause

Related to a major life change

Something Else

Which of the following best describes them?

Which of the following best describes them?*

<12 Years Old

13-17 Years Old

18-24 Years Old

25-29 Years Old

30-39 Years Old

40-49 Years Old

50-59 Years Old

60-69 Years Old

70+ Years Old

What types of challenges do they face? Select All that apply.

Select All that apply

What types of challenges do they face? Select All that apply.*

Have they ever been diagnosed with a mental health issue?

Have they ever been diagnosed with a mental health issue?*

Yes

To your knowledge, which of the following mental health conditions were they diagnosed with?

Select all that apply.

To your knowledge, which of the following mental health conditions were they diagnosed with?*

ADHD

PTSD

Depression

Anxiety

Bipolar Disorder

Schizophrenia

Something Else

What best describes how the mental health issue began?

What best describes how the mental health issue began?*

Gradual over time

Triggered by a specific event

Following a traumatic experience

Sudden onset without a clear cause

Related to a major life change

Something Else

Have they previously sought help managing the mental health issue before?

Have they previously sought help managing the mental health issue before?*

Yes

How should we reach out to you about setting up an appointment?

First Name*

Last Name*

Email*

e.g. email@domain.com

Phone*

e.g. (555) 555-5555

Comments

This field is for validation purposes and should be left unchanged.

Find Mental Health Support

Multi Page Form

What kind of treatment plan are you trying to make?

Who are you seeking services for?

Which of the following best describes you?

As a minor* I need help and I’ve talked with my parent about this.

What types of challenges do you face?

Have you ever been diagnosed with a mental health issue?

To your knowledge, which of the following mental health conditions have you been diagnosed with?

Have you previously sought help managing the mental health issue before?

What best describes how the mental health issue began?

Which of the following best describes them?

What types of challenges do they face? Select All that apply.

Have they ever been diagnosed with a mental health issue?

To your knowledge, which of the following mental health conditions were they diagnosed with?

What best describes how the mental health issue began?

Have they previously sought help managing the mental health issue before?

How should we reach out to you about setting up an appointment?

Request An Appointment

Find Mental Health Support

Multi Page Form

What kind of treatment plan are you trying to make?

Who are you seeking services for?

Which of the following best describes you?

As a minor* I need help and I’ve talked with my parent about this.

What types of challenges do you face?

Have you ever been diagnosed with a mental health issue?

To your knowledge, which of the following mental health conditions have you been diagnosed with?

Have you previously sought help managing the mental health issue before?

What best describes how the mental health issue began?

Which of the following best describes them?

What types of challenges do they face? Select All that apply.

Have they ever been diagnosed with a mental health issue?

To your knowledge, which of the following mental health conditions were they diagnosed with?

What best describes how the mental health issue began?

Have they previously sought help managing the mental health issue before?

How should we reach out to you about setting up an appointment?

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