OSS Care Pre-Screening Questionnaire

Please answer the following questions to the best of your ability

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* 1. State Your Full Name

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* 2. As a patient, do you prefer

Male Therapist

Female Therapist

It doesn't matter

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

Yes

No

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

Yes

No

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* 5. How long have you had your symptoms?

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

Yes

No

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* 7. List all the symptoms you've experience in the past 30 days

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

Yes

No

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