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What is the reason for seeking care?

Anxiety Attentional difficulties Depression Grief Relationship issues Trauma Chronic health issues 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

What does your support system look like?

Family members, friends, partner, religious or other community

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What are your hopes/goals for therapy?

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