Freespira Enrollment Form

1

What is your name?* This field is required.We need to collect your information to share your results with you.

First Name

Last Name

2

What is your email address?* This field is required.

example@example.com

3

Please select your health insurance.* This field is required.

4

How did you hear about Freespira?* This field is required.

5

Which symptoms would you like to check?* This field is required.

Panic

PTSD

6

How do you self-identify?* This field is required.

Male

Female

Non-Binary

Other

7

Is there any chance you are pregnant right now? * This field is required.

YESNO

8

Have you been diagnosed with COPD or emphysema?* This field is required.

Yes

No

9

Have you had COVID or any other respiratory condition in the last month?

YESNO

10

Have you had seizures?

YESNO

11

Have you ever been diagnosed with bipolar disorder, psychosis, or delusional disorder?* This field is required.

YESNO

12

Which disorder?* This field is required.

13

Do you have a history of suicide attempts or suicidal thoughts?* This field is required.

YESNO

14

Are you currently feeling suicidal or have thoughts of suicide?* This field is required.

YESNO

15

If you’re ever struggling or need crisis support, you can call or text 988 for the National Crisis and Support Lifeline. The Lifeline is available 24/7.

16

Your safety is our top priority. We recommend you pause this survey and ask you to call or text 988, the Suicide and Crisis Lifeline. The Lifelife offers free, private support 24/7. For other types of emergencies, call 911.

17

Are you planning to take any vacations or extended time away from home during your treatment?

YESNO

18

Can you commit to doing two 17-minute breathing sessions each day for 28 days?* This field is required.

YESNO

19

What could make it difficult to complete two treatment sessions a day?

20

We have just a few more questions about your symptoms.

Please select the answer that best indicates how much you have been bothered by that problem in the past month.

21

Repeated, disturbing, and unwanted memories of the stressful experience* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

22

Repeated, disturbing, and unwanted dreams of the stressful experience* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

23

Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

24

Feeling very upset when something reminded you of the stressful experience* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

25

Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

26

Avoiding memories, thoughts, or feelings related to the stressful experience* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

27

Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

28

Trouble remembering important parts of the stressful experience* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

29

Having strong negative beliefs about yourself, other people, or the world (e.g., having thoughts such as, "I am bad," "there is something seriously wrong with me," "no one can be trusted," "the world is completely dangerous," etc.* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

30

Blaming yourself or someone else for the stressful experience or what happened after it* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

31

Having strong negative feelings such as fear, horror, anger, guilt, or shame* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

32

Loss of interest in activities that you used to enjoy* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

33

Feeling distant or cut off from other people* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

34

Trouble experiencing positive feelings (e.g., being unable to feel happiness or have loving feelings for people close to you)* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

35

Irritable behavior, angry outbursts, or acting aggressively* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

36

Taking too many risks or doing things that could cause you harm* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

37

Being “superalert” or watchful or on guard* This field is required.

Not at all

A little bit

Moderately

Quite a bit

Extremely

41

We will review your information and contact you to get started. How would you like us to contact you?* This field is required.Select all that apply

Phone Call

Email

SMS

42

What is the best time to contact you during the week?Please include your timezone and preferred contact method (phone, text, email).

43

PTSD Diagnosed

TRUEFALSE

44

Name

First Name

Last Name

45

Phone Number

46

Email

example@example.com

47

Is Pregnant

TRUEFALSE

48

Not Pregnant

TRUEFALSE

49

Yes to disorder

TRUEFALSE

50

no to disorder

TRUEFALSE

51

Dilusional Disorder

TRUEFALSE

52

Bipolar

TRUEFALSE

53

Psychosis

TRUEFALSE

54

Never suicidal

TRUEFALSE

55

yes to suicidal thoughts before

TRUEFALSE

56

not currently suicidal

TRUEFALSE

57

is currently suicidal

TRUEFALSE

59

symptom count #

60

PDSS Q1

61

PDSS Q2

62

PDSS Q3

63

PDSS Q4

64

PDSS Q5

65

PDSS Q6

66

PDSS Q7

67

PDSS total score

68

q1pcl5sf

69

q2pcl5sf

70

q3pcl5sf

71

q4pcl5sf

72

q5pcl5sf

73

q6pcl5sf

74

q7pcl5sf

75

q8pcl5sf

76

q9pcl5sf

77

q10pcl5sf

78

q11pcl5sf

79

q12pcl5sf

80

q13pcl5sf

81

q14pcl5sf

82

q15pcl5sf

83

q16pcl5sf

84

q17pcl5sf

85

q18pcl5sf

86

q19pcl5sf

87

q20pcl5sf

88

total pcl5 score

89

PANIC ATTACKS YES OR NO

TRUEFALSE

90

pcl5 above threshold

TRUEFALSE

91

pdss above threshold

TRUEFALSE

92

over18

TRUEFALSE

93

bipolar,dd,spy yes no

94

covid recently

95

preferred method

96

most recent lead source detail

97

status

yes

unsure

no

Type option 4

98

DO answer to tx

99

utm source

100

utm campaign2

101

utm content

103

UTM Campaignhttps://form.jotform.com/243314772914155

104

UTM Campaignhttps://form.jotform.com/243314772914155

105

UTM Termhttps://form.jotform.com/243314772914155

106

do you have a disorder

107

108

PCL5 Name

109

first name

110

last name

111

Email

example@example.com

112

Phone Number

Area Code

Phone Number