You can always press Enter⏎ to continue
articleCreated with Sketch.
Welcome to Grand Island Mental Health & Medical Clinic!
We are excited to get to know you better! 
articleCreated with Sketch.
Language
  • English (US)
  • Español
  • 1
    Press
    Enter
  • 2
    Press
    Enter
  • 3
    Press
    Enter
  • 4
    -
    Pick a Date
    Press
    Enter
  • 5
    (Ex: If treatment was successful in what ways would you be able to tell?)
    Press
    Enter
  • 6
    Press
    Enter
  • 7
    Press
    Enter
  • 8
    Press
    Enter
  • 9
    Press
    Enter
  • 10
    Check all that apply.
    Press
    Enter
  • 11
    Check all that apply.
    Press
    Enter
  • 12
    Ex: It has been 3 years and I was 32 years old.
    Press
    Enter
  • 13
    Check all that apply.
    Press
    Enter
  • 14
    Ex: It has been 3 years and I was 32 years old.
    Press
    Enter
  • 15
    Press
    Enter
  • 16
    Select all that apply.
    Press
    Enter
  • 17
    Select all that apply.
    Press
    Enter
  • 18
    Please choose all that apply.
    Press
    Enter
  • 19
    Please choose all that apply.
    Press
    Enter
  • 20
    Please choose all that apply.
    Press
    Enter
  • 21
    Press
    Enter
  • 22
    Please list information about all of your children
    Press
    Enter
  • 23
    Press
    Enter
  • 24
    I am the _____ (st/nd/rd/th) sibling in a line of _____ siblings.
    Press
    Enter
  • 25
    Press
    Enter
  • 26
    Please choose all that currently apply.
    Press
    Enter
  • 27
    Press
    Enter
  • 28
    Press
    Enter
  • 29
    Please list all past care.
    Press
    Enter
  • 30
    Press
    Enter
  • 31
    Please list all previous care.
    Press
    Enter
  • 32
    Please indicate the symptoms you are CURRENTLY experiencing and HOW LONG you have experienced them
    1 of 41
    Press
    Enter
  • 33
    Please indicate if you or a family member has been diagnosed with any of the following:
    1 of 14
    Press
    Enter
  • 34
    If there is currently any suicide risk please seek help and call the National Suicide Hotline at 1-800-273-8255
    1 of 3
    Press
    Enter
  • 35
    If you responded "none" to all questions please write n/a.
    Press
    Enter
  • 36
    (This includes social drinking and any prescription drug not prescribed to you)
    Press
    Enter
  • 37
    Press
    Enter
  • 38
    Press
    Enter
  • 39
    Press
    Enter
  • 40
    Press
    Enter
  • 41
    Press
    Enter
  • 42
    Press
    Enter
  • 43
    • Currently serving
    • Honorably discharged
    • Dishonorably discharged
    • Other than honorably (OTH) discharged
    • General discharge
    • Bad conduct discharge
    Press
    Enter
  • 44
    Press
    Enter
  • 45
    Press
    Enter
  • 46
    Press
    Enter
  • 47
    Please choose all that apply.
    Press
    Enter
  • 48
    Press
    Enter
  • 49
    Press
    Enter
  • 50
    Press
    Enter
  • 51
    Press
    Enter
  • 52
    Press
    Enter
  • 53
    Press
    Enter
  • 54
    Press
    Enter
  • 55
    Press
    Enter
  • 56
    Press
    Enter
  • 57
    • Yes, obtained diploma
    • Not completed
    • GED obtained
    • Yes, obtained diploma
    • Not completed
    • GED obtained
    Press
    Enter
  • 58
    Press
    Enter
  • 59
    Press
    Enter
  • 60
    Press
    Enter
  • 61
    1 of 10
    Press
    Enter
  • 62
    Press
    Enter
  • 63
    Please list any and all medication you are currently taking including over the counter medications
    Press
    Enter
  • 64
    Press
    Enter
  • 65
    Press
    Enter
  • 66
    (You can ask for a copy of these Terms, Conditions, and Client Rights and Responsibilities at any time)
    Press
    Enter
  • 67
    The easiest way to get information quickly is by "liking" and checking our Facebook page for holiday and weather related closings and office updates 
    Press
    Enter
  • Should be Empty:
Question Label
1 of 67See AllGo Back
close