Freespira Digital Onboarding

1

Are you over 18?* This field is required. Freespira is available to adults and teens age 13 and over

YESNO

2

Are you over 13?* This field is required. Freespira is available to adults and teens age 13 and over

YESNO

3

You are ineligible for Freespira treatment. Freespira is available to adults and teens age 13 and over. Please click Submit to exit the survey.

4

What would you like Freespira to help you with?* This field is required.

Panic attacks

PTSD symptoms

Panic and PTSD symptoms

Something else

I'm not sure

5

What's your e-mail address?

example@example.com

6

Got it. We can ask again at the end of the survey. We won't be able to follow up with your results unless we have your email.

We want you to know that we are committed to keeping your personal info safe. Your emailI address wilIl never be shared, and you can unsubscribe at anytime.

7

Please describe what you would like Freespira to help you with:* This field is required.

8

If you have been diagnosed with PTSD, when were you diagnosed?* This field is required.

Less than 1 year ago

1-5 years ago

5-10 years ago

More than 10 years ago

I haven't been formally diagnosed

9

The next set of questions ask about your symptoms. This will help us to track your improvement with Freespira. We know that questions about your symptoms can be triggering. If you'd rather answer later, we can follow up with you.* This field is required.

Continue to questions

I'd prefer to do this later

10

Do you experience panic attacks?* This field is required.

Yes

No

12

This question talks about 2 different types of panic attacks. Full panic attacks have at least 4 symptoms. Limited symptom attacks have 3 symptoms or fewer. How many of each type did you have in the past month?* This field is required.

No full panic attacks or limited symptom attacks

No full panic attacks. I had some limited symptom attacks, but no more than 1 per day

1 or 2 full panic attacks and/or multiple limited symptom attacks per day

More than 2 full attacks but not more than 1 per day on average

Full panic attacks more than once a day, more days than not

13

In the past month, how distressing were the attacks you had on average?* This field is required.

Not at all distressing, or I didn't have any panic attacks or limited symptom attacks

Mildly distressing (not too intense)

Moderately distressing (intense, but still manageable)

Severely distressing (very intense)

Extremely distressing (extreme distress during all attacks)

14

In the past month, how often did you feel anxious or worried about your next panic attack?* This field is required.

Not at all

Occasionally or only mildly

Frequently or moderately

Very often or to a very disturbing degree

Nearly constantly and to a disabling extent

15

Some people avoid places or situations where they fear having a panic attack. In the past month, how often did you feel afraid or avoid things because of panic attacks?* This field is required.

No fear or avoidance

Occasional fear or avoidance. But I managed to get through the situation and didn't have to make too many adjustments.

Noticeable fear or avoidance. I could get through some situations with a companion, but I did have to adjust my lifestyle. Overall, I was able to do what I needed to do.

Avoiding certain situations meant I had to make major changes in my lifestyle. It was hard to manage my usual activities.

My fear or avoidance was so strong that I simply couldn't do important things.

16

Some people fear doing certain things because the physical feelings remind them of a panic attack. Or they may fear causing an attack. It can be exercise, sex, or bathing. Or it can be drinking coffee or watching a scary movie. In the past month, how often did you feel afraid or avoid activities like this?* This field is required.

I didn't fear or avoid any situations

I felt afraid or avoided things a bit. But usually I could confront it and it wasn't too bad.

I avoided things enough that it meant shifting my lifestyle a bit. But I was able to do what I needed to do.

Avoiding things meant major shifts in my lifestyle. It was hard to do what I needed to do.

My fear or avoidance was so strong that I simply couldn't do important things.

17

Some people fear doing certain things because of the physical sensations they cause. It may remind them of a panic attack. Or they may fear bringing on an attack. It can be exercise, bathing, drinking coffee, or watching a scary movie. In the past month, how often did you feel afraid or avoid activities like this?* This field is required.

I didn't fear or avoid any situations.

I felt afraid or avoided things a bit. But usually I could confront it and it wasn't too bad.

I avoided things enough that it meant shifting my lifestyle a bit. But I was able to do what I needed to do.

Avoiding things meant major shifts in my lifestyle. It was hard to do what I needed to do.

My fear or avoidance was so strong that I simply couldn't do important things.

Other

18

Panic attacks and limited symptom attacks can make it hard to live your life. So can fear and avoidance caused by panic attacks. Think about the past month. How much did these things get in the way of your ability to work or handle responsibilities at home?* This field is required.

They didn't interfere at all.

They interfered a little, but I could do nearly everything I could if I didn't have these problems.

They interfered significantly, but I still could manage to do the things I needed to do.

They interfered a lot. There were many important things I couldn't do because of these problems.

These problems made me essentially unable to manage any work or home responsibilities.

19

Panic attacks, limited symptom attacks, fear, and avoidance can get in the way of your social life. How much was this true for you over the past month?* This field is required.

It didn't get in the way at all.

It held me back a little, but I could do nearly everything I could if I didn't have these problems.

It was a barrier, but I could manage to do most things if I made the effort.

It really held me back from social activities. There were many things I couldn't do.

There was hardly anything social I could do.

21

Could you be pregnant right now?* This field is required.

YESNO

22

We can't offer treatment right now if you're pregnant. If you share your name, e-mail and due date, we can follow up in the future to see if you're still interested in Freespira.

Name

Please enter your email

Due date

23

Have you ever been diagnosed with bipolar disorder, psychosis, or delusional disorder?* This field is required.

Yes

No

I'm not sure

Other

24

Have you ever thought about suicide or tried to end your life?* This field is required.

YESNO

25

Are you having thoughts of killing yourself right now?* This field is required.

YESNO

26

Your safety is our top priority. We recommend you pause this survey and ask you to call or text 988, the Suicide and Crisis Lifeline. The Lifelife offers free, private support 24/7. For other types of emergencies, call 911.

27

If you’re ever struggling or need crisis support, you can call or text 988 for the National Crisis and Support Lifeline. The Lifeline is available 24/7.

28

Are you eligible for benefits through the Veterans Health Administration?This will help us verify your coverage and out-of-pocket costs for Freespira.

YESNO

29

What is your health insurance member ID number? You can usually find it on your member ID card.Nothing will be billed to your insurance. You won't be charged unless you consent to treatment with Freespira.

30

What is your health insurance Group ID number? You can usually find it on your member ID card.Nothing will be billed to your insurance. You won't be charged unless you consent to treatment with Freespira.

31

What is your name?* This field is required.

First Name

Preferred Name

Last Name

32

How did you hear about Freespira?* This field is required.

33

What state do you live in?

34

What's your e-mail address?* This field is required.

example@example.com

35

What's your phone number?* This field is required.

Please enter a valid phone number.

36

Disclaimer* This field is required.

37

What is your birth date?

Date

38

Thank you for completing this survey! Our team will follow up with you regarding next steps. How would you prefer us to follow up?* This field is required.We’ll do our best to use your preferred method, but may reach out another way if we can’t reach you

Phone

Text

Email

39

The following questions ask about your PTSD symptoms. This will help us to track your improvement with Freespira. We know that questions about your trauma symptoms can be triggering. If you'd rather answer later, we can follow up with you.* This field is required.

Continue to the questions

I'd rather do this later

40

Repeated, disturbing, and unwanted memories of the stressful experience* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

41

Repeated, disturbing dreams about the stressful experience* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

42

Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

43

Feeling very upset when something reminded you of the stressful experience* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

44

Having strong physical reactions when something reminded you of the stressful experience (for example heart pounding, trouble breathing, or sweating)* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

45

Avoiding memories, thoughts, or feelings related to the stressful experience* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

46

Avoiding reminders of the stressful experience (for example people, places, conversations, activities, objects, or situations)* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

47

Trouble remembering important parts of the stressful experience* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

48

Having strong negative beliefs about yourself, other people, or the world. (This could be thoughts like: I am bad, there is something seriously wrong with me, no one can be trusted, or the world is completely dangerous.)* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

49

Blaming yourself or someone else for the stressful experience or what happened after it* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

50

Having strong negative feelings such as fear, horror, anger, guilt, or shame* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

51

Loss of interest in activities that you used to enjoy* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

52

Feeling distant or cut off from other people* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

53

Trouble experiencing positive feelings (for example, being unable to feel happy or have loving feelings for people close to you)* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

54

Irritable behavior, angry outbursts, or acting aggressively* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

55

Taking too many risks or doing things that could cause you harm* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

56

Being super alert, watchful, or on guard* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

57

Feeling jumpy or easily startled* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

58

Having difficulty concentrating* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

59

Trouble falling or staying asleep* This field is required.How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

61

Disease State

PTSD

Panic

Panic & PTSD

Other

62

PDSS Name

63

PCL5 Name

65

Other Pronoun Notes API

66

Is patient Veteran

TRUEFALSE

68

symptom count

69

PDSS Q1

70

PDSS Q2

71

PDSS Q3

72

PDSS Q4

73

PDSS Q5

74

PDSS Q6

75

PDSS Q7

76

Adolecsent

TRUEFALSE

77

PCL5 Q1

78

PCL5 Q2

79

PCL5 Q3

80

PCL5 Q4

81

PCL5 Q5

82

PCL5 Q6

83

PCL5 Q7

84

PCL5 Q8

85

PCL5 Q9

86

PCL5 Q10

87

PCL5 Q11

88

PCL5 Q12

89

PCL5 Q13

90

PCL5 Q14

91

PCL5 Q15

92

PCL5 Q16

93

PCL5 Q17

94

PCL5 Q18

95

PCL5 Q19

96

PCL5 Q20

97

PDSS Total Score

98

PCL5 Total Score

99

Insurance Name

100

Most Recent Lead Source Detail

101

Not Pregnant

YESNO

102

Not Suicidial In the Past

YESNO

103

Not Suicidal Right Now

YESNO

104

Email

example@example.com

105

UTM Source

106

UTM Term

107

UTM Campaign

108

UTM Content

109

UTM Medium