My Ideal Therapist

Hello, and thanks for reaching out. Mental Health is Health, and we are committed to providing you with compassionate and competent care. As you may be able to tell, The Northrop Connection has a variety of providers and services. This survey is going to help us to match you with your ideal therapist and services, and we want to make it as easy as possible for you to be connected with the proper care. This survey is confidential. It will be reviewed by our Practice Owner (Jessica Northrop) or Office Manager (Angie Downing). Based on your responses, our Office Manager or your matched Therapist will be reaching out to you to schedule an appointment within 1 business day from the completion of this survey.

If you find that you cannot wait that long, please contact your primary care provider, the Emergency Room, the Georgia Crisis Access Line (1-800-715-4225) or the Nationwide Mental Health Crisis Hotline (988, call or text). Georgia also has a "Warm Line" that is available if you just need to talk to someone quickly but are not in a crisis: 770-276-2019.

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* 1. Name

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* 2. How do you prefer to be contacted? Please note: we will not be able to contact you unless you complete this information.

Phone (enter phone number)

Email (enter email address)

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* 3. Would you rather work with a male or female Therapist?

Male

Female

No Preference

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* 4. Where do you prefer to receive services?

Mostly In Person in our Dallas Office (I'm okay with telehealth if there is a health concern).

I prefer the convenience of Telehealth, and I have a safe, secure place to conduct my Telehealth sessions with adequate wifi.

I prefer my child to be seen in their school during the school day (this option is available for Nebo Elementary School, Abney Elementary School, Burnt Hickory Elementary School, and Sammy McClure Middle School (Paulding)).

No Preference.

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* 5. What is your funding for therapy? Please check all that apply.

I have insurance, and I wish to work with an in-network provider.

I have insurance, and while I prefer an in-network provider, I am comfortable using out of network benefits.

I don't have insurance, and I need someone who can offer a sliding scale.

I don't have insurance and am comfortable paying the full session fee.

I would like to talk to the Office Manager about payment options.

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* 6. What is your insurance company (you can type N/A if you don't have insurance)?

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* 7. What types of services are you interested in? Please check all that apply.

Individual Therapy (Adult)

Couples or Family Therapy

Individual Therapy (Child or Adolescent, ages 6-17)

Medication Evaluation (An evaluation does not compel you to take medication, but will give you information about what medications may help.

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* 8. What are some areas in your life that you want help with? Please check all that apply.

I've been dealing with mood problems. This can include sadness, crying spells, difficulty getting out of bed, poor motivation, mood swings, feeling hopeless, frustrated with life in general, and I can be really irritable.

I've been dealing with Anxiety. This may include intense worry, difficulty being around people, panic attacks, and avoidance of situations where I think I'm likely to become anxious.

Overuse of substances including drugs, alcohol, food, or difficulty controlling other behaviors, such as gambling, internet, shopping, sex, or other.

I've had a trauma in my life, and I' would like to see if there's a therapist whom I can really trust to help me get through it.

I have a chronic illness, and I'd like help understanding the brain-body connection so I can manage my illness.

Relationship difficulties

Problems at work or school

I'm not sure, but I feel like I need to talk to someone to sort out all of the thoughts and situations I'm dealing with.

I'm pregnant, have given birth in the last year, or have suffered the loss of a pregnancy. I would like someone who has expertise in maternal mental health.

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* 9. How did you hear about us?

Search Engine

Facebook

Referred by a friend or family member

Referred by my doctor or other medical provider

Referred by my insurance.

My child was referred by a School Counselor.

Psychology Today

Other (please specify)