PHP/IOP Questionnaire – Overcoming Counseling Center

Name

First

Last

Date of Birth

Please enter your date of birth using MMDDYYYY format

Email

Confirm Email

Enter the best email to contact you

Phone Number

Enter the best number to contact you

Have you been experiencing worsening mental health symptoms?

Have you had any recent hospitalizations or emergency room visits for psychiatric concerns?

If your you

If you answered “yes” to above, please describe

Have you been diagnosed with any mental health conditions?

If you answered “yes” to above, please describe

What symptoms are you currently experiencing?

Which treatment preferences are you interested in?

If you answered “other” above, please describe

Have your mental health symptoms affected your daily life?

Have you had thoughts of harming yourself or others?

Have you ever attempted suicide or engaged in self-harm

If you answered “yes” to above, when was the most recent time?

Do you have a plan or intent to harm yourself or others now?

What is the best time of day to contact you?

How would you like to pay?

Insurance Carrier

Self-Pay Please select your insurance carrier or self-pay

Insurance ID

What is your insurance ID number, if applicable? Please enter N/A if you will be using self-pay

Therapy Focus

What is bringing you into therapy at this time?

Comments or Questions