Are you reaching out for yourself, a loved one or yourself and a loved one?(Required)

Myself

Loved One

Myself and A Loved One

Are you struggling with anxiety, depression or different mental health concern.(Required)

Yes

No

Is your loved one struggling with anxiety, depression or a different mental health concern.(Required)

Yes

No

Have you ever received a mental health diagnosis?(Required)

Yes

No

Has your loved one ever received a mental health diagnosis?(Required)

Yes

No

When would you like to start treatment?(Required)

When would they like to start treatment?(Required)

Are you currently struggling with an addiction?(Required)

Yes

No

Are they currently struggling with an addiction?(Required)

Yes

No

What resources do you have to cover the cost of treatment(Required)

Private Insurance (Aetna, Cigna, Blue Cross, Humana, etc.)

Cash Pay (pay per session)

Medicaid

Medicare

What resources do they have to cover the cost of treatment(Required)

Private Insurance (Aetna, Cigna, Blue Cross, Humana, etc.)

Cash Pay (pay per session)

Medicaid

Medicare

What is your biggest motivation for treatment?(Required)

What is their biggest motivation for treatment?(Required)

Do you consider yourself religious or spiritual?(Required)

Yes

No

Does your loved one consider themselves religious or spiritual?(Required)

Yes

No

Do you currently have a therapist?(Required)

Yes

No

Does your loved one currently have a therapist?(Required)

Yes

No

How do you feel that the therapy is going?(Required)

How do they feel that the therapy is going?(Required)

Contact Information

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

What is your preferred method of contact?(Required)

Text

Call

E-mail

Your Loved One's Contact Information

Their Name(Required)

Their Last Name(Required)

Their Phone(Required)

Their Email(Required)

What is their preferred method of contact?(Required)

Text

Call

E-mail

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