Mental health and addiction assessment

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Care Star BHS, LLC is committed to protecting your privacy and all protected health information. This brief assessment is to gather information about your current situation and see if our programs will be a good fit for your needs. All information provided is secure and will never be shared with any third party without your consent. We want to help you any way we can and are committed to doing so quickly and efficiently* This field is required.
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What type of help are you seeking today?
Addiction Treatment Services
Mental Health Services
Alcohol Treatment Services
Psychiatry
Med Mangement
Counseling
3
What is your timeline for starting treatment?* This field is required.
As soon as possible
Next week
Within two weeks
Not sure yet
4
Are you looking for in-person or virtual treatment options?
In-personVirtual/Hybrid
5
Who are you looking to help?* This field is required.
MyselfA loved one
6
Are you looking for help with Mental Health or Drugs/Alcohol?* This field is required.If both apply, which affects you the most?
Mental HealthDrugs/Alcohol
7
Have you used drugs or alcohol in the last 14 days?* This field is required.
Yes
No
Not Sure
8
What best describes your job?
Business owner
Executive/White-collar professional
Skilled trade/Blue-collar worker
Retail employee
Military veteran
Government worker
Healthcare professional
Other
9
What service are you looking for today?Mental Health
Psychiatric evaluation
Group Therapy
Med Management
Ketamine Testing
ADHD Testing
TMS (Transcranial Magnetic Stimulation)
Other
10
Would you be able to attend in-person* This field is required.
YesNo
11
If treatment required travel but airfare, stay, and basic expenses were covered, would you be able to attend?
YESNO
12
Do you have a vehicle?* This field is required.
YESNO
13
Our clinic is located at 3032 E. Hebron Pkwy, Suite 102, Carrollton, TX 75010. Is this a commute you are willing and able to make at least once per week?* This field is required.
YESNO
14
Where did you get your health insurance?* This field is required.
Marketplace healthcare
Through my spouse
Through my employer
Veterans Affairs
I do not have health insurance
I will pay out of pocket
Other
15
Below is a list of our in-network partnerships. Which of these do you currently have? .* This field is required.If you do not have one of these, please select “Not sure” so we can discuss availability
Aetna
Blue Cross Blue Shield
Cigna
Tricare/Triwest
Humana
Magellan
Not Sure
16
Do you currently have your insurance card available?
YESNO
17
Upload a copy of your insurance card (front and back) (Optional)Optional
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Do you have any challenges that might make starting difficult right now?
Scheduling/time
Transportation
Child care
Financial stress
None
Other
19
Policyholder InformationPlease provide insurance details (this helps with faster admissions)
Insurance Policy Holder Name
Date of Birth
Member ID Number
Group ID Number
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How would you like us to reach out to you?
Phone
Text
Email
Whatever is fastest
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Are you able to show up as scheduled and respect our team’s time?* This field is required.
YESNO
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Name* This field is required.
First Name
Last Name
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Phone Number* This field is required.
Please enter a valid phone number.
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Email* This field is required.
example@example.com
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How did you hear about us* This field is required.
Referred by someone
Facebook
Instagram
Google Search
Pinterest
Blog Page
Youtube
Third Party Website
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Appointment
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