1

Do you have any chronic medical conditions?

Yes

No

2

If yes, which chronic medical conditions?

3

Do you live in one of the following states?New York, California, Colorado, Washington, Texas, Michigan

YESNO

4

We're sorry.

We're not in every state yet but if you'd like to leave your contact info, we'll be sure to reach out to you as soon as we are!

5

Are you 18 or older?

YESNO

6

Not yet available.

We're sorry we can’t yet treat individuals in your area or under 18 years old. However, please use our contact form if you would like to be notified when your location or age becomes available.

7

Feeling nervous, anxious, or on edge* This field is required.

Not at all

Several days

More than 1/2 the days

Nearly every day

8

Not being able to stop or control worrying* This field is required.

Not at all

Several days

More than 1/2 the days

Nearly every day

9

Little interest or pleasure in doing things* This field is required.

Not at all

Several days

More than 1/2 the days

Nearly every day

10

Feeling down, depressed, or hopeless* This field is required..

Not at all

Several days

More than 1/2 the days

Nearly every day

11

PHQ2 Total

12

GAD2 Total

13

PHQ4

14

What's your name?* This field is required.

First Name

Last Name

15

What's your date of birth?* This field is required.

16

Which mobile number can we reach you at?* This field is required.

Please enter a valid phone number.

17

What's your email address?* This field is required.

example@example.com