Wellness Insight Questionnaire

1
*Disclaimer: Your privacy is our priority. All information shared is confidential, securely stored, and protected under HIPAA regulations. It will only be used to assess your needs and provide the highest quality care.

We value your time. This form should take no more than 5-7 minutes.

Thank you for considering Behavioral Wellness for Women to support you on your wellness journey. We don't take this lightly! We are a boutique women’s mental wellness clinic providing personalized, high-quality psychiatric care for women. Due to high demand, we thoughtfully select new clients to ensure the best experience. This brief questionnaire helps us determine if our services are the right fit for you. If accepted, you will receive next steps, including scheduling your initial psychiatric evaluation.

Please Note:

We specialize in women’s mental health, including anxiety, depression, and perinatal mood concerns.

We do not provide ADHD evaluations or initiate stimulant prescriptions, but we do support women with an existing ADHD diagnosis.

We do not provide individual therapy but offer medication management with brief supportive therapy.

We are an out-of-network provider for all Pennsylvania insurance plans except Aetna. Additionally, we are out of network for all New Jersey residents, regardless of insurance. If you do not have Aetna or you reside in New Jersey, you will be responsible for private payment. Superbills will be provided upon request.
2
Name* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
What kind of support are you looking for?* This field is required.
Medication management
Second opinion
Medication management & second opinion
Other
5
We encourage you to share anything else you'd like us to know about your current situation.Optional
Huge
Large
Normal
Small
Ok
Ok
6
Are you a Pennsylvania or New Jersey resident?* This field is required.
I am a Pennsylvania resident and I HAVE Aetna insurance.
I am a Pennsylvania resident. I understand that I will have to pay privately for services and a superbill will be provided upon request.
I am a New Jersey resident. I understand that I will have to pay privately for services and a superbill will be provided upon request.
7
Have you ever been diagnosed with a mental health condition? If so, what was/were your diagnosis(es)?* This field is required.
Depression
Anxiety
OCD
Panic attacks
ADHD
Bipolar I
Bipolar II
Psychosis
Sleep disorder
Anorexia
Bulimia
Binge eating disorder
Substance abuse
No
Other
8
Have you ever worked with a psychiatric nurse practitioner, psychiatrist, or other mental health prescriber for medication management?* This field is required.
YESNO
9
Are you currently taking medication for mental health?* This field is required.
YESNO
10
If so, what medication(s) are you taking?
Huge
Large
Normal
Small
Ok
Ok
11
In the past six months, have you had any significant mental health concerns that required urgent or emergency care or inpatient psychiatric hospitalization?* This field is required.
YESNO
12
Are you currently struggling with an active eating disorder (i.e. anorexia, bulimia, binge eating disorder, or other disordered eating behaviors)?* This field is required.
Yes, I am currently struggling with an active eating disorder.
No, I have a history of eating disorder and I am not currently struggling.
No, have never been diagnosed with an eating disorder.
13
How did you hear about Behavioral Wellness for Women?* This field is required.
My therapist
Friend/family/colleague
Google ads
Social media
Other
14
I understand that Behavioral Wellness for Women does not provide new ADHD diagnoses or prescribe stimulant medications to individuals who are not currently on them or have never been prescribed them. I understand that a past stimulant prescription does not guarantee that stimulants will be restarted.* This field is required.
I have read and understand the information above.
15
Important Next Step for Aetna Clients

Please carefully review the following:

• Completing your Headway profile is required in order to be seen. This allows us to verify your insurance and bill for your appointment.

• Your Headway profile must be fully completed at least 48 hours before your appointment.

• We highly recommend completing your Headway profile as soon as possible to allow enough time for insurance verification.

• If your insurance is not verified or your profile is incomplete, your appointment will be canceled.

To continue:

• Click “Submit” below to complete this form and move forward with scheduling your appointment.
16
Thank you so much for sharing with us. Based on your responses, it sounds like you may benefit from more specialized support to best meet your current needs. We thoughtfully screen all potential clients to ensure we're the right fit, and to make sure you receive the highest quality care-whether that's with us or another trusted provider.

Resources

Providers

P.S. Psychiatry

Psychiatric Associates of Pennsylvania

Psychology Today

National Crisis Lifeline

Call or text 988

Philadelphia

Philadelphia Warmline (855) 507-9276

NAMI Philadelphia Warmline (267) 687-4381

Montgomery County

Perr Support Talk Line (855) 715-8255

New Jersey

Peer Recovery WarmLine (877) 292-5588

National Maternal Mental Health Hotline

Call or Text 1-833-852-6262

Postpartum Support International (PSI) HelpLine

Call or text 1-800-944-4773 (4PPD)

We are truly grateful you considered us as part of your care journey, and we wish you nothing but wellness and support as you take your next steps.
Should be Empty: