Qualtrics Survey | Qualtrics Experience Management

What is your name?

Who is completing this referral form (e.g., self, family member, provider)?

Name and contact (if not self)

How can we contact you?

Phone
Email

What is your date of birth?

Do you have health insurance? If so, what kind.

Yes
No

What services are you interested in receiving or would like to know more about? Please select all that apply:

Starting care with a new doctor (i.e., psychiatrist) to learn about medication options
Starting therapy with a psychologist (individual or group therapy to work on your own recovery goals)
Completing assessment to figure out my diagnosis and the best treatment options, and/or completing testing to request accommodations for school
Learning more about research studies I might be able to enroll in
Family services (education or therapy)

We require participants to utilize both psychiatric (i.e., medication or check-ups) and psychological (e.g., therapy, or at least occasionally checking in with a therapist for treatment and/or case management) services. Are you willing to see both our psychiatrist and one of our therapists?

Yes
No

Have you been diagnosed with a mental health disorder? If so, please list your diagnosis in the text box after the "Yes" option.

Yes
No