Request appointment | Been There Counseling

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

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

Thank you for filling out this form before we meet. The questions here will help us during our initial call. If you are currently experiencing any emergency please immediately call 911 as we are unable to provide 24 hour support or assist with crisis emergencies.

I understand that you do not offer 24 hour and/or emergency services and I am not experiencing an emergency

I understand that you do not offer 24 hour and/or emergency services and I am not experiencing an emergency Other:

Have you met with a therapist in the last 1-3 years?

If Yes please share a little regarding what you worked on in therapy before and share any previous mental health diagnosis.

Limited to 600 characters

Please give a brief description as to why you are seeking therapy (describe the problem and when it started):

Limited to 600 characters

What are you hoping to achieve in therapy? Please list your top possible 1-3 goals you'd like to achieve in therapy (how would you like your life to look, feel, or be different at then end of our work together)?

Limited to 600 characters

Have you experience any signifiant changes in your life in the last year (Example: Job Change, Retirement, Grieving, Ending of a Relationship, Moving, Parenting, Family Changes, Health Issues, and so on).

Limited to 600 characters

Have you ever been hospitalized for mental health treatment?

Yes

What year did you receive treatment and how long was the treatment No

Do you have suicidal thoughts, a plan to harm yourself, or history of suicide attempts? Please also list below and any self-harming behaviors/history.

Limited to 600 characters

Do you have any issues leaving your house?

Do you have any safety issues such as in an abusive relationship, housing / living arrangement issues, and so on?

Limited to 600 characters

Please list any questions or concerns you have about therapy or the counseling process (For example, session times, insurance, cost, frequency, and so on).

Limited to 600 characters

Thank you for completing this questionnaire. Amy will call you at the start time of the consultation. Please make sure you are in a private location where you can talk freely about your answers. We look forward to learning more about you soon!

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