Request appointment | Pacific Anxiety Group

What type of therapy are you seeking?

Adult Therapy (18+) Child Therapy (5-12) Teen Therapy (13-17) Parent-Coaching (self-pay only) Couples Therapy (self-pay only) Group Therapy

In a few sentences (2–4), please share what you, or the person you are seeking therapy for, would like help with in therapy. This information helps us match you with a clinician who has the right expertise, so please include enough detail to help us determine a good fit.

For example, you may want to include some information about current symptoms, concerns, and/or goals you have for treatment. If you’d prefer to keep this brief for now, we may reach out to set up a brief phone consultation to learn more about what you are looking for to help us better match you with a clinician.

Limited to 600 characters

What are the main concerns you're seeking help for:

We recommend selecting up to 5 issues you'd like to address in therapy.

Which concern is the most important right now?

This helps us find a clinician who is a good match.

For the concerns listed above, how much are these affecting your work, school, or daily functioning?

Not impacting at all Mild impact on daily life Moderate impact on daily life Severely impacting my ability to function

Have you, or the person you're seeking services for, ever been diagnosed with or currently experiencing any of the following:

Bipolar 1 disorder Schizophrenia Psychosis Substance-use disorder None of the above

Please let us know if any of the following are applicable to you, or the person you are seeking therapy for:

Currently in therapy Attended therapy in the past Currently working with a psychiatrist Currently taking psychiatric medications None of the above

In the past 6 months, have you, or the person you're seeking services for, been hospitalized for a mental health, drug, or alcohol-related issue?

Yes No

Have you, or the person you are seeking therapy for, ever been hospitalized for psychiatric care?

Yes No

In the past 6 months, have you, or the person you are seeking therapy for, experienced thoughts of harming yourself?

Yes No

Have you, or the person you are seeking therapy for, ever experienced thoughts of harming yourself?

Yes No

Have you, or the person you are seeking therapy for, ever experienced thoughts of harming someone else?

Yes No

Do you, or the person you are seeking therapy for, have a history of any self-harm?

Yes No

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