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What is the reason for seeking care?

Check as many as apply.

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Trauma Social Skills issues Academic issues

What kind of care is being sought?

*no medication services are available

Psychotherapy Psychological Testing Both Therapy and Testing Not Sure

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

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