Fill out the short questionnaire to help us hit the ground running on our call ⬇️

Fill out the short questionnaire to help us

hit the ground running on our call ⬇️

What is your gender?

Man

Woman

Other

Prefer not to say

How old are you?

How old are you?

What led you to consider psychiatric care today?

(Please go beyond saying “depressed” or “anxious.” Share how these symptoms are affecting your daily functioning, mood, or overall quality of life.)

*

What are some of the things you are struggling with?

I have difficulty focusing or staying on task.

I often feel easily distracted or forgetful.

I struggle with organization or time management.

I frequently start tasks but have trouble finishing them.

I feel restless or find it hard to sit still.

I tend to act impulsively or make quick decisions without thinking.

I often feel mentally drained or overwhelmed by daily responsibilities.

I get frustrated easily or experience mood swings.

My attention difficulties are affecting my work, school, or relationships.

How long have you ben experiencing these struggles?

0-3 months

3-6 months

1-2 years

2+ years

Have you been in therapy before?

Yes

No

Which state are you in?

Texas

New Mexico

Not in Texas or New Mexico, and I will leave this page immediately.

You have completed the questionnaire!

Let's get you scheduled for a

15-minute consultation.

First Name *

Last Name *

Phone *

Email *

I agree to the Privacy Policy and Terms & Conditions provided by the company. By providing my phone number, I agree to receive sms messages from the business to schedule a free consultation.

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What is your gender?

Man

Woman

Other

Prefer not to say

How old are you?

How old are you?

What led you to consider psychiatric care today?

(Please go beyond saying “depressed” or “anxious.” Share how these symptoms are affecting your daily functioning, mood, or overall quality of life.)

*

What are some of the things you are struggling with?

I have difficulty focusing or staying on task.

I often feel easily distracted or forgetful.

I struggle with organization or time management.

I frequently start tasks but have trouble finishing them.

I feel restless or find it hard to sit still.

I tend to act impulsively or make quick decisions without thinking.

I often feel mentally drained or overwhelmed by daily responsibilities.

I get frustrated easily or experience mood swings.

My attention difficulties are affecting my work, school, or relationships.

How long have you ben experiencing these struggles?

0-3 months

3-6 months

1-2 years

2+ years

Have you been in therapy before?

Yes

No

Which state are you in?

Texas

New Mexico

Not in Texas or New Mexico, and I will leave this page immediately.

You have completed the questionnaire!

Let's get you scheduled for a

15-minute consultation.

First Name *

Last Name *

Phone *

Email *

I agree to the Privacy Policy and Terms & Conditions provided by the company. By providing my phone number, I agree to receive sms messages from the business to schedule a free consultation.

NEXT

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