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 Couples Therapy Group Therapy

Please briefly describe the issues or goals that you, or the person you are seeking therapy for, would like to address in therapy:

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.

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

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