Self-Screen Survey

1
What would you like Freespira to help you with?
Anxiety attacks or panic attacks
PTSD symptoms
2
Your responses are private and secure. They will only be used to help determine your potential eligibility for treatment.

If it looks like you are a candidate for Freespira, we will follow up to offer further help. You can opt out of these messages at any time.
3
Are you over 18?* This field is required.
YESNO
4
Are you over 13?
YESNO
5
Sorry, Freespira is only available for 18+ currently. Please select Submit or close your web browser to exit the survey.

Please talk with your regular physician or therapist about your symptoms and interest in treatment.
6
What's your email address?* This field is required.We'd like to share your results with you after you complete the survey.
example@example.com
7
Panic/anxiety attacks are sudden episodes of intense fear or anxiety, often with physical symptoms. Do you have these?
YESNO
8
If you are not experiencing panic attacks. Would you like to restart the survey, talk to a patient advisor, or get help with PTSD (post-trauma) symptoms?
Restart the survey
Schedule a call with a patient advisor
Take PTSD symptom screener
9
The next questions are about panic attack symptoms that can be distressing for some people. What would you like to do next?
Continue to questions about panic attack symptoms
Schedule a call with a patient advisor
10
Do panic attacks bother you a lot or do you worry about having another one?
YESNO
11
Do you sometimes change your plans or avoid certain places because of your panic attacks?
YESNO
12
Did you feel short of breath?
YESNO
13
Did you feel dizzy, unsteady, lightheaded, or faint?
YESNO
14
Did your heart race, pound, or skip?
YESNO
15
Did you tremble or shake?
YESNO
16
Did you sweat?
YESNO
17
Did you feel like you were choking?
YESNO
18
Did you have nausea or an upset stomach?
YESNO
19
Did you feel numbness or tingling in any part of your body?
YESNO
20
Did you have hot flashes or chills?
YESNO
21
Did you have chest pain or discomfort?
YESNO
22
Did you feel afraid you were dying?
YESNO
23
Did you feel out of control?
YESNO
24
Have you experienced something unusually or especially frightening, horrible, or traumatic?For example, physical assault or abuse, sexual assault or abuse, a serious accident or fire, an extreme weather event, seeing someone seriously injured or killed, having a loved one die through homicide or suicide, or a war.
YESNO
25
If you are not experiencing PTSD symptoms, would you like to restart the survey, talk to a patient advisor, or get help with panic attack/disorder symptoms?
Restart the survey
Schedule a call with a patient advisor
Take panic attack/disorder symptom screener
26
The next questions are about PTSD symptoms that can be distressing for some people. What would you like to do next?
Continue to questions about PTSD symptoms
Schedule a call with a patient advisor
27
In the past month, have you had nightmares about the event or thought about it when you didn’t want to?
YESNO
28
In the past month, have you tried hard not to think about the event, or went out of your way to avoid situations that reminded you of it?
YESNO
29
In the past month, have you been constantly on guard, watchful, or easily startled?
YESNO
30
In the past month, have you felt numb or detached from people, activities, or your surroundings?
YESNO
31
In the past month, have you felt guilty or unable to stop blaming yourself or others for the event or any problems it may have caused?
YESNO
32
What is your name?* This field is required.
First Name
Preferred Name
Last Name
33
What is your mobile phone number?* This field is required.By sharing your number, you agree to receive calls or texts at this number. You may withdraw your consent at any time by emailing us at par@freespira.com or by replying STOP to a text message.
Please enter a valid phone number.
34
How did you hear about Freespira?
Please Select
Please Select
Billboard Ad
Blog
Bus Ads
Case Manager
Clinician/Provider
Community Event
Direct Mailer
Email
Facebook Ads
Google Ads
Google Search
LinkedIn Ads
News Media
Newsletter
Other
Phone Call
SMS Message
Social Media
Webinar
Word of Mouth
35
Based on your answers, we believe Freespira can likely help you with your symptoms. Nearly 9 out of 10 people with similar symptoms found significant relief with Freespira, and 7 out of 10 were panic attack-free after treatment.
36
We recommend speaking with a Freespira patient advisor. An advisor can answer questions, check insurance coverage, and help you get started with Freespira. How would you like to move forward?
I'd like to schedule a call with a patient advisor
I'd like to get started with the Freespira treatment
I need more information before I make a decision.
37
Who is your health insurance provider or employer?If you have health insurance, Freespira may be covered by your plan. Nothing will be billed to your insurance until you begin treatment.
Please Select
Please Select
Chorus Community Health Plans
Comcast
Harvard Pilgrim Health Care
Highmark Health
Security Health Plan
Veterans Administration (VA)
Aetna
Allied Benefit Systems
AmeriHealth
Anthem
Aurora
BCBS
CarePlus
Cigna
Exclusive Care Plan
Fidelis Care
Forward Health
Geisinger
HAP/AHL/Curanet
HealthNet
Humana
Kaiser Permanente
Magnacare
MetroPlus
Molina
National Benefit Fund
Nova Healthcare
Optima Health
Oscar
Oxford Freedom
Priority Health
Tricare
United
UPMC
Other
No insurance/I don’t plan to use my insurance
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Please specify the health insurance provider or employer:
39
Thank you! Click Submit to schedule a call with a patient advisor. If you have any questions, you can reach our team at par@freespira.com.
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Great! Once you click “Submit” below, you’ll be directed to our online onboarding
tool where you’ll answer another series of questions about your symptoms.

Your answers will help us further understand your treatment needs.

It will take a few minutes to complete.
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Lead Source Detail
42
insurance NAme
43
Payment Source API
CCHP
SHP
Point32Health
VA
Tri-Care
Comcast
Highmark
Self Pay
Out_of_Network
44
Nurture api
YESNO
45
Disease state
Panic
PTSD
46
UTM Source
47
UTM Term
48
UTM Campaign
49
UTM Content
50
UTM Medium
51
API Last Name
First Name
Last Name
Should be Empty: