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What brings you to therapy at this time?

What symptoms are you experiencing, and how are they impacting your daily life?

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Have you been to therapy before?

If so, where and with whom? What was the outcome of that treatment?

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Have you ever been given a mental health diagnosis?

If yes, please share.

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Is there anything we should know about the type of therapy you are seeking or any preferences or requirements you have for your provider?

For example: lived experience, identity, approaches, or modalities.

Are you interested in learning more about any of the following supports?

Selecting options does not commit you to services or guarantee availability.

Individual therapy only Case management – help navigating resources, systems, and practical barriers (available to clients with Medicaid/OHP) Peer support – non-clinical support grounded in lived experience (available to clients with Medicaid/OHP) Medication management with a psychiatric prescriber (available to most clients) Therapy groups – skill-based, process-oriented, or identity-affirming groups (available to all clients) Not sure / open to discussing Not interested at this time

If you selected therapy groups, what types of groups are you most interested in?

Skills-based groups (coping skills, emotion regulation, etc.) Process or support groups Identity-affirming groups (LGBTQIA+, shared lived experience, etc.) Not sure / open to recommendations Not interested in groups at this time

Are there any other areas of support you are hoping to receive help with, or services you are looking for referrals to that are not listed above?

Have you ever been hospitalized or received a higher level of mental health care?

Do you or your loved ones have concerns about substance use?

Do you have concerns about personal safety, housing, food access, or basic needs?

Do you have any accessibility needs we should be aware of?

If yes, please explain.

Anything else you'd like us to know?

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