First Name
*
Last Name
*
Phone
*
Email
*
Over the last 2 weeks, have you experienced any anxiousness or feeling "on edge"?
Yes
No
Over the last 2 weeks, have you experienced any excess worry?
Yes
No
Over the last 2 weeks, have you been unable to relax?
Yes
No
Over the last 2 weeks, have you been irritable?
Yes
No
Over the last 2 weeks, have you been concerned with imminent danger?
Yes
No
If you checked "Yes" to any of the above items, briefly describe how that has affected your daily living.
Over the last 2 weeks, have you experienced little interest or pleasure in doing things.
Yes
No
Over the last 2 weeks, have you experienced feeling hopeless?
Yes
No
Over the last 2 weeks, have you experienced trouble falling asleep or sleeping too much?
Yes
No
Over the last 2 weeks, have you experienced having too little energy or being tired?
Yes
No
Over the last 2 weeks, have you experienced a poor appetite or over-eating?
Yes
No
Over the last 2 weeks, have you experienced believing you are a failure?
Yes
No
Over the last 2 weeks, have you experienced trouble concentrating?
Yes
No
Over the last 2 weeks, have you experienced believing you would be better off dead?
Yes
No
Please provide a list of all medications you are currently taking, including dose and frequency.
What brings you to counseling? Please be specific.
Authorization agreement
*
I authorize The Still Waters to communicate with me per Telehealth.
I authorize The Still Waters to charge my credit/debit card on file for sessions according to the agreed upon schedule and consents.
I understand and commit to the confidentiality incurred to me and the counselor, according to the HIPPA act. (Health Insurance Portability and Accountability Act)