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What is the reason for seeking care?

Anxiety Depression Disordered Eating Problematic Behaviour Grief Relationship issues Substance use Trauma Other

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

What are your goals that you would like to achieve while you are in therapy?

Enter the outcomes you are hoping to achieve by attending therapy

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