Mental Health Screen
Thank you for choosing Reach for Tomorrow.This confidential screening helps us determine the services that best meet your needs.• Takes approximately 5–7 minutes• Your information is securely transmitted• An Intake Coordinator will contact you within 48 business hours. If you are experiencing a mental health emergency or are in immediate danger, call 911 or 988 before completing this form.
Today's date
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Month
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Day
Year
Date
Back
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Client Full Name
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First Name
Last Name
Client Date of Birth:
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Month
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Day
Year
Date
Client Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Email Address
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example@example.com
Client Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Name and Member ID
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What location are you needing?
Kingston
Piketon
Malta
Adams
Age Group?
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Under 18- Complete the Guardian information below
Over 18
Guardian Full Name
First Name
Last Name
Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian Date of birth
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Month
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Day
Year
Date
Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What would you like help with today? What brings you to seek mental health services?
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Which of the following are you currently experiencing?
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Anxiety
Depression or low mood
Stress
Grief or loss
Relationship issues
Sleep difficulties
Suicidal thoughts
Trauma/PTSD
Other
Do you currently take medications? (OTC or prescriptions)
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Are you currently having thoughts of hurting yourself?
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Yes
No
Are you currently having thoughts of hurting someone else?
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Yes
No
How did you hear about Reach for Tomorrow?
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When are you generally available?
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Morning
Afternoon
Evening
Weekends
Can we leave a voicemail?
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Yes
No
Can we text you?
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Yes
No
If yes, What is a good text number?
Is there anything else you would like us to know?
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Submit
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