test form - Mindfuli

First, please tell us a little about yourself.

This information will be kept confidential and helps us ensure were able to provide you with care.

Your primary home address

Primary street address

Apt, suite, etc. (optional)

Tell us what brings you to therapy?

Select all that apply

Now, we have a few questions about your mental health history.

Our Promise

We’ll never share your personal information with anyone without your permission.

We follow HIPAA regulations, so your responses are always secure.

Is this your first time seeking care for a mental health problem?

Yes No

Are you currently taking any medication to manage a mental health problem?

Yes No

In the past six months, have you been hospitalized as a result of a mental health, drug or alcohol problem?

Yes No

Do you feel like you are at risk of killing yourself?

Yes No

If you or someone you know is in crisis, call 911 or the National Suicide Prevention Hotline 1-800-273-8255 right away.

Next, we’ll ask you a few questions about your mental health.

This will help your matching therapist better understand your mental health history and match you to the right care provider.

In the last 6 months, have you ever experienced symptoms of or been diagnosed with:

Depressive Disorder

Feelings of severe hopelessness, helplessness, low energy, anhedonia, poor appetite or overeating, inability to concentrate, isolation, insomnia or over sleeping, excessive crying spells.

Yes No I'm not sure

Anxiety Disorder

Feelings of worthlessness, extreme irritability, agitation, poor concentration, increased heart rate, excessing sweating, being uncomfortable in public settings, panic attacks, and or excessive worrying about the future.

Yes No I'm not sure

Bipolar Disorder, Mania

This includes experiencing extreme mood swings, such as times when you feel unusually high or hyper and times when you feel low or depressed.

Yes No I'm not sure

In the last 6 months, have you ever experienced symptoms of or been diagnosed with:

Psychotic Disorders such as; Schizophrenia, Schizoaffective, Paranoia, and or Delusions.

This includes unusual experiences that some people have like seeing or hearing things that other people cannot see or hear.

Yes No I'm not sure

Personality Disorders/other disorders

Borderline Personality Disorder, Dissociative Identity Disorder, Narcissistic Personality Disorder, Histrionic Personality Disorder, Obsessive Compulsive Disorder, and or Attention Deficit Hyperactivity.

Yes No I'm not sure

Eating Disorder; Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, Restrictive Food Intake

This includes feeling out of control of your eating, such as eating too little or too much, feeling very distressed or worried about your weight or body, and feeling like food dominates your life.

Yes No I'm not sure

In the last 6 months, have you ever experienced symptoms of or been diagnosed with:

Drugs or alcohol use

This includes frequent or excessive use of alcohol and/or drugs that interferes with your daily activities and/or causes health problems.

Yes No I'm not sure

Trauma, Post-traumatic Stress Disorder (PTSD)

This includes intense, disturbing, thoughts and feelings related to a traumatic event, such as a serious accident, sexual or physical assault, natural disaster, or the violent or sudden death of someone close to you.

Yes No I'm not sure

Suicidal Ideation, Homicidal Ideation and or Self harm

This includes intentionally harming or hurting yourself (e.g., cutting, burning, scratching)

Yes No I'm not sure

Verification of Benefits

Instructions: