OSS Care Pre-Screening Questionnaire

Please answer the following questions to the best of your ability...

Question Title

* 1. State your Full Name

Question Title

* 2. I am looking for...

1 Session Assessment

On going sessions

Only Court ordered sessions

Question Title

* 3. As a patient, I prefer a...

Male Therapist

Female Therapist

It doesn't matter

Question Title

* 4. Have you had suicidal thoughts/tendencies in the past 30 days

Yes

Question Title

* 5. Over the past month, have you felt down or helpless?

Yes

Question Title

* 6. How long have you had your symptoms?
List your symptoms

Question Title

* 7. Do you have any personal or family history of mental health issues?

Yes

Question Title

* 8. Would you like an OSS Care Staff to contact you?

Yes

OSS Care Pre-Screening Questionnaire

Please answer the following questions to the best of your ability...

Question Title

* 1. State your Full Name

Question Title

* 2. I am looking for...

Question Title

* 3. As a patient, I prefer a...

Question Title

* 4. Have you had suicidal thoughts/tendencies in the past 30 days

Question Title

* 5. Over the past month, have you felt down or helpless?

Question Title

* 6. How long have you had your symptoms?
List your symptoms

Question Title

* 7. Do you have any personal or family history of mental health issues?

Question Title

* 8. Would you like an OSS Care Staff to contact you?

Question Title

* 9. If "YES" what is your email address and phone number?

Question Title

* 10. Who Referred you to us?
Write name of individual or company

OSS Care Pre-Screening Questionnaire

Please answer the following questions to the best of your ability...

Question Title

* 1. State your Full Name

Question Title

* 2. I am looking for...

Question Title

* 3. As a patient, I prefer a...

Question Title

* 4. Have you had suicidal thoughts/tendencies in the past 30 days

Question Title

* 5. Over the past month, have you felt down or helpless?

Question Title

* 6. How long have you had your symptoms?List your symptoms

Question Title

* 7. Do you have any personal or family history of mental health issues?

Question Title

* 8. Would you like an OSS Care Staff to contact you?

Question Title

* 9. If "YES" what is your email address and phone number?

Question Title

* 10. Who Referred you to us?Write name of individual or company

* 6. How long have you had your symptoms?
List your symptoms

* 10. Who Referred you to us?
Write name of individual or company