Request appointment | Crystal Clear Mental Health, LLC

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

What kind of care is being sought?

Psychotherapy Medication Other Not sure

Have you ever been hospitalized for psychiatric reasons?

No Yes, once Yes, multiple times

Have you ever attempted suicide?

No Yes, once Yes, multiple times

Do you have a history of self harm (cutting, burning, ect)?

No Yes, once Yes, currently

Do you have a history of substance abuse?

No Yes, in the past Yes, currently

Do you currently have a psychiatric prescriber?

No Yes

Have you had previous psychiatric providers?

No Yes

Have you ever been discharged or dismissed from a psychiatric practice?

No Yes

Are you currently prescribed any controlled substances for mental health or other conditions?

No Yes

Are you currently on any psychiatric medications?

You will be asked to list meds at the end.

No Yes, less than 5 medications Yes, 5 or more medications

Have you ever had legal issues related to mental health, substance use or violence?

No Yes, in the past Yes, recent/ongoing

Have you ever been involuntarily committed for psychiatric treatment?

No Yes

Do you have any history of violence or aggression toward healthcare providers?

No Yes

Do you have a history of medication non-compliance (stopping meds on your own, not taking as prescribed)?

No Yes, occassionally Yes, frequently

Please list all current medications, dosages and frequency.

Include the last time taken.

Limited to 600 characters

Please list all prior medications. Not current medications.

Include the last time taken.

Limited to 600 characters