Therapy

Therapy Intake Survey

This survey is simply a preliminary questionnaire that helps us get to know you. We use this info to create a personalized experience tailor-made just for you. After finishing the survey, you may use the Positivity+ app to reserve a session.

    General Info

    We put privacy first. This info is for our eyes only. Any information provided by you is used to understand your needs and provide a better service. We may use your information for the following: to fulfill your requests in a timely and effective manner, to improve our products or services based on your needs, or to personalize your experience according to your interests. ATMH will not sell, share, or distribute your personal information to third parties.

    First

    Last

    City

    State/Province

    Email

    Phone

    Birth date

    Referred by

    How did you hear about us?

    Insurance

    If you plan to use your insurance, please fill out the fields below. This information will be found on your insurance card.

    Company

    ID/Contract Number

    Group Number

    Effective Date

    Demographics

    We ask the following information because we would like to get to know you better. Your info is confidential and privacy is important. Any information provided by you is used to understand your needs and provide a better service.

    Gender

    Age

    Race/Ethnicity

    Preferred Language

    Relationship Status

    Identify as

    HEALTH QUESTIONS

    Over the last 2 weeks, how often have you been bothered by any of the following problems?

    Little interest or pleasure in doing things

    Feeling down, depressed, or hopeless

    Trouble falling asleep, staying asleep, or sleeping too much

    Feeling tired or having little energy

    Poor appetite or overeating

    Feeling bad about yourself, or that you are a failure or have let yourself or your family down

    Trouble concentrating on things such as reading the newspaper or watching television

    Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual

    Thoughts that you would be better off dead or of hurting yourself

    How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

    More About You

    Over the last 2 weeks, how often have you been bothered by any of the following problems?

    Feeling nervous, anxious, or on edge

    Not being able to stop or control worrying

    Worrying too much about different things

    Trouble relaxing

    Being so restless that it is hard to sit still

    Becoming easily annoyed or irritable

    Feeling afraid, as if something awful might happen

    How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

    Therapist Preference

    Preference

    Follow-up Questions

    Have you ever been in counseling or therapy before?

    How would you rate your current physical health?

    How would you rate your current eating habits?

    Are you experiencing overwhelming sadness, grief, or depression

    Are you currently employed?

    Do you have any problems or worries about intimacy?

    How often do you drink alcohol?

    When was the last time you thought about suicide?

    Are you currently experiencing anxiety, panic attacks, or have any phobias?

    Are you currently taking any medication?

    Are you currently experiencing and chronic pain?

    How would you rate your current sleeping habits?

    Additional Info

    Please provide us with any additional information you think we should know. Also, we are always open to feedback and suggestions so feel free to speak your mind. We’re here to answer any of your questions or concerns.

    WHAT'S NEXT?

    After submitting this form, you may use the Positivity+ app to join your session and schedule future sessions. Please click the Send button below.

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