1. Are you referring to yourself or a loved one?
*
Myself
A loved one
Is your loved one willing to engage is treatment
Yes
No
Unsure
What insurance carrier do you have?
Medicaid
Medicare
None
Unsure
Private/Other
You selected Private/Other above. Please write in what insurance you have.
What is your preferred method of contact? (select all that apply)
Email
Phone call
Text
Enter your phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Enter your email
example@example.com
What is the primary concern that is causing you to reach out?
*
Substance Use
Mental Health
Housing Instability
Other
Back
Next
Substance Use
What is the substance(s) of choice? (Select all that apply)
Alcohol
Prescription Opioids
Street Opioids
Meth
Crack/Cocaine
Marijuana
Other
Unsure
How often is the substance use?
Daily
Multiple times a week
Weekly
Multiple times a month
Monthly
Other
Unsure
Has substance use caused any of the following experiences? (Select all that apply)
Frequent black outs
Loss or excessive strain on relationships
Loss of employment
Chronic Health Conditions
Destruction of Property
Other
Unsure
How long has it been since the last episode of use
Currently intoxicated
Yesterday
A few days ago
Last week
A couple of weeks ago
Over a month ago
Unsure
What level of treatment do you think is right for you or your loved one’s substance use treatment?
Medically Monitored Withdrawal Management (Detoxification)
Residential (in-patient) treatment
Daily Outpatient Support
Sober Living
Outpatient Therapy
Unsure
Are there other concerns you would like Tellurian to address with you?
*
No
Yes, Mental Health
Yes, Housing Instability
Other
Back
Next
Mental Health
What mental health concern is currently the most concerning?
Suicidal thoughts
Thought of self-harm of harming others
Actions of self-harm or harming others
Depression
Anxiety
Auditory Hallucinations
Grief
Trauma
Other
Unsure
What other mental health concerns are present? (Select all that apply)
Suicidal thoughts
Thought of self-harm of harming others
Actions of self-harm or harming others
Depression
Anxiety
Auditory Hallucinations
Grief
Trauma
Other
Unsure
Have you or your loved one experienced any of the following due to mental health struggles? (Select all that apply)
Excessive strain on relationships
Loss of employment
Self-Harm
Harm to others
Suicidal thoughts or actions
Panic attacks
Repetitive thoughts or actions that interfere with daily living
Isolation
A manic episode
Other
What level of treatment do you think is right for you or your loved one’s mental health care?
Crisis stabilization
Inpatient support
Case management / home visit support
Outpatient therapy
Unsure
Are there other concerns you would like Tellurian to address with you?
*
No
Yes, Substance Use
Yes, Housing Instability
Other
Back
Next
Housing Instability
What is you or your loved one’s current housing situation
Currently housed but instable
Living with friends or family
Unhoused
Other
Unsure
Do you currently have any income?
No
Yes, SSI/SSDI
Yes, employed
What type of housing services are you looking for?
Group home living
Sober living home
Support housing
Transitional living
Case management or service facilitation support
Unsure
Are there other concerns you would like Tellurian to address with you?
*
No
Yes, Substance Use
Yes, Mental Health
Other
Back
Next
Other Concerns
Please share what concerns you have.
Back
Next
Is there anything else you would like to share with us?
Submit
Should be Empty: