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What is the reason for seeking care?

Anxiety Bullying Relationship issues Stress Burnout Life Transitions School Issues Attachment Issues Trauma Other

What kind of care is being sought?

Psychotherapy Medication Other Not sure

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 Attempted suicide in the past None of these apply

Are you a resident of Mississippi or Texas?

(Do you live in Mississippi or Texas?)

Yes No

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