OSS Care Pre-Screening Questionnaire
Please answer the following questions to the best of your ability...
1.
State your Full Name
2.
I am looking for...
1 Session Assessment
On going sessions
Only Court ordered sessions
3.
As a patient, I prefer a...
Male Therapist
Female Therapist
It doesn't matter
4.
Have you had suicidal thoughts/tendencies in the past 30 days
Yes
No
5.
Over the past month, have you felt down or helpless?
Yes
No
6.
How long have you had your symptoms?
List your symptoms
7.
Do you have any personal or family history of mental health issues?
Yes
No
8.
Would you like an OSS Care Staff to contact you?
Yes
No
9.
If "YES" what is your email address and phone number?
10.
Who Referred you to us?
Write name of individual or company
Current Progress,
0 of 10 answered