Candidate Survey 2.0 (Combined)

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Please note:

This assessment is intended only to educate, not to determine eligibility for treatment or provide a clinical diagnosis.

Eligibility for treatment is determined by a Mindbloom Psychiatric Clinician after reviewing all client intake information and conducting an in-person evaluation.
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submission_uuid
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Are you at least 18 years old?* This field is required.
YESNO
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Tell us about your depression symptoms over the past 7 days* This field is required.
Never
Rarely
Sometimes
Often
Always
I felt worthless
I felt helpless
I felt depressed
I felt hopeless
I felt worthless
I felt helpless
I felt depressed
I felt hopeless
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
1 of 4
5
Depression score(Hidden from users)
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Tell us about your anxiety symptoms over the past 7 days* This field is required.
Never
Rarely
Sometimes
Often
Always
I felt fearful
I found it hard to focus on anything other than my anxiety
My worries overwhelmed me
I felt uneasy
I felt fearful
I found it hard to focus on anything other than my anxiety
My worries overwhelmed me
I felt uneasy
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
1 of 4
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Anxiety score(Hidden from users)
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Are you currently prescribed medication for depression or anxiety?* This field is required.
Yes, for depression
Yes, for anxiety
Yes, for both
Nope
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What's your email?* This field is required.We'll use this to save your responses.
example@example.com
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Do any of the following apply to you?* This field is required.Mindbloom isn't a fit for certain people or conditions. If you are in a life-threatening situation, call the National Suicide Prevention Line at +1 1-800-273-8255, call 911, or go to the nearest emergency room. Responses are not monitored in real-time by Mindbloom.
Under 18 years old
Primary psychotic disorder (e.g., schizophrenia, schizoaffective disorder)
Prepared for or attempted to end your life (in the past year)
Method, intent, or plan to commit suicide (in the past month)
Biological female who is pregnant, nursing, or trying to become pregnant
None of the above
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Please provide more detail about the conditions you selected* This field is required.
Huge
Large
Normal
Small
Ok
Ok
12
Do any of the following conditions currently apply to you?* This field is required.Responses are not monitored in real-time by Mindbloom. If you are in a life-threatening situation, call 911 or go to the nearest emergency room.
Untreated high blood pressure
Serious heart problems (e.g., congestive heart failure, abnormal heart rhythm)
Severe breathing problems
Psychotic or manic symptoms
Serious medical illness not listed above
Substance abuse or dependence
Alcohol abuse or dependence
Biological female who is pregnant, nursing, or trying to become pregnant
None of the above
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Please provide more detail about the current conditions you selected* This field is required.
Huge
Large
Normal
Small
Ok
Ok
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Where are you?* This field is required.Let's see if our licensed psychiatric clinicians serve your state.
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Finally, how did you hear about us?* This field is required.Please select all that apply
Word of mouth
Referred by my medical provider
Referred by a Mindbloom client
Google search
Social media
Outdoor poster
Press
Podcast
Outdoor poster
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Referrals warm our hearts!* This field is required.Who referred you to Mindbloom?
Name
Relationship to you
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You may be a great candidate for Mindbloom!

Click "SUBMIT" to create your Mindbloom account and start your journey
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