Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

Anxiety/Worry Panic Attacks Depression/Sadness Mood Swings Irritability Trauma or Flashbacks Grief or Loss Stress/Overwhelm Difficulty focusing Sleep Issues Appetite Changes Low Motivation Parenting Stress Pregnancy Challenges Postpartum Challenges Infertility Challenges Other

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply