Step 1 of 9
Welcome. I’m pleased that you have chosen to take this step. I look forward to working with you.
This questionnaire is for the purpose of getting to know you better in order to provide the best possible mental health services. Please complete this form as honestly and completely as possible. All information that you provide us will be confidential as required by state and federal law.
*Note: Email correspondence and texts are not guaranteed as a confidential method of communication. If you choose to use either one, please be sure to limit it to details like scheduling as well as billing ONLY. Please DO NOT send an email to cancel or confirm a scheduled appointment. Please ONLY text me to confirm, cancel or change an appointment (48 hours cancelation policy still applies though. Third party payers do not cover late cancelations or missed appointments, which would become your sole responsibility, regardless of whether you choose to use your insurance or not). Additionally, unless in case of a true emergency, I may choose not to respond to the question outside of an appointment, unless strictly related to rescheduling or billing, as I do not provide email or text therapy. Thank you for respecting this professional boundary.
Thoughts about suicide. Can be active or passive and can be with or without intent or a plan. Passive: General feelings of not wanting to be alive Active: Wanting to commit suicide in the present, often times with a specific plan and intent (having the intention of completed suicide)
If you don’t feel safe around yourself, please call 911 immediately or go your nearest hospital or emergency room, please avoid drugs and alcohol, make your home safe by getting rid of all knives, razors, pills, and any firearms. Please don’t keep those suicidal feelings to yourself!
