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You Heal Psychotherapy Services, LLC
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Treatment Assessment Form
First name
*
Last name
*
Email
*
Phone
*
What brings you to therapy? (Select all that apply)
*
I'm feeling overwhelmed or anxious.
I'm experiencing sadness or depression.
I'm struggling with past trauma(s).
I want help improving my relationships.
I need support managing stress or life changes.
I'm facing family or parenting challenges.
I'm looking for help with personal growth.
Other
Who is seeking out therapy?
*
Myself
My child/teenager
My partner
A family member
Other
Have you experienced any of the following recently? (Select all that apply)
*
Difficulty sleeping or eating.
Trouble concentrating or making decisions.
Changes in mood or energy levels.
Feelings of isolation or loneliness.
Emotional reactions to specific events or memories.
Difficulty managing anger or frustration.
What are you looking to accomplish in therapy?
*
Reduce stress or anxiety.
Heal from past trauma(s).
Improve communication skills.
Build healthier relationships.
Develop coping strategies.
Boost confidence and self-esteem.
Other
What is your preferred method of communication?
*
Mobile/Telephone
Email
No preference
Any additional information you'd like to share with our team?
Submit
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