CFA - Intake Form

  • Welcome to Center for Anxiety

  • We’re really glad you reached out!

    This brief form helps us understand your situation so we can connect you with the right level of care and clinician. It usually takes about 5–6 minutes to complete.

    There are no right or wrong answers - just be as honest as you can. Everything you share will be treated with care and kept confidential, and will only be used to ensure you receive the support that fits you best.

     

    How it works:

    Step 1 — Complete This Form
    You’re here now! This helps us understand your background, goals, and preferences so we can find the right fit.

    Step 2 — Join Your Free Consultation
    You've already scheduled a call with one of our Client Care Specialists using Calendly. During this conversation, we'll discuss your needs and match you with the clinician or program that fits best.

    Step 3 — Begin Care
    Once matched, you’ll start therapy with your clinician quickly and seamlessly. Whether you’re beginning individual sessions, DBT, IOP, or another program, we’ll make sure you get the right level of help fast.


    Before you begin:

    This form is not a clinical assessment and is not monitored by a clinician. It is reviewed by our administrative team solely to help match you with the most appropriate services at the Center for Anxiety. If you are experiencing a mental health or medical emergency, please do not complete this form. Instead, call 911, go to your nearest emergency department, or contact the National Suicide and Crisis Lifeline by dialing 988 for immediate support.

  • Demographic & Background

    Parents/Guardians: Please use your child’s name and answer all questions about your child, not yourself.
  • Format: (000) 000-0000.
  • Preferred Contact Method
  • Date of Birth*
     - -
  • How did you hear about Center for Anxiety?*

  • Presenting Concerns

  • How long have these concerns been present?
  • Have you ever received professional mental health treatment (e.g., psychotherapy, medication)?
  • Has your treatment been helpful?
  • Have you ever been hospitalized for mental health reasons?

  • How have you been feeling lately?

    The next few questions ask about your mood, anxiety, and general wellbeing. Your responses will help us understand how you’ve been feeling and how we can best support you. There are no right or wrong answers - just choose what feels most accurate for you over the past two weeks.
  • Feeling nervous, anxious, or on edge
  • Not being able to stop or control worrying
  • Little interest or pleasure in doing things
  • Feeling down, depressed, or hopeless
  • Have you had thoughts of hurting yourself or wishing you were dead?
  • Have you intentionally hurt yourself (e.g., cutting), even if you did not want to die?
  • Have you used alcohol or drugs in a way that worries you, or would worry others?
  • Is your mental health interfering with your daily life (e.g., work, school, relationships)?
  • Which areas are most affected? (Select all that apply)

  • What's going well?

    We’d also like to learn about your strengths and sources of support - what helps you cope and what gives your life meaning. There are no right or wrong answers here - just share whatever feels true for you over the past two weeks.
  • Do you have at least one friend or family member you can turn to for support?
  • How ready are you to make changes to improve your mental health?
  • How hopeful do you feel that your mental health can improve?
  • What type of support are you most interested in? Select all that apply.*
  • If you have a general idea of when you’re most available, please let us know below (select all that apply)
  • When would you like to begin your therapy sessions?
  • In what setting would you like to see a clinician?

  • By submitting this form, you acknowledge that your information will be reviewed by our intake team to determine the most appropriate next steps. You will be contacted within one business day.

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