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Pre-Screening Form-ESA
Please complete each question to the best of your ability. All information is kept confidential and stored according to HIPPA compliance measures.
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Email
*
Your email
Full Name
*
Your answer
Address
*
Your answer
Phone
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Non-Binary
Referral Source (List Promo Code if applicable)
*
Your answer
Do you currently own a pet?
*
Yes
No
Current Medical Condition
*
Choose
Anxiety
Depression
PTSD
Panic
ADHD
Social Phobia
Chronic Stress
Other
Please rate the intensity of your current symptoms (i.e. How much does it disrupt your daily activities?)
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1
2
3
4
5
6
7
8
9
10
Your Consultation Obligations: I have read and understood my obligations for consultation through the Oasis Center. Should we refer you to a licensed mental health professional in your state for an evaluation...
*
I understand that I may be evaluated by that mental health professional using distance therapy or teletherapy.
I understand that the mental health professional will perform the evaluation under the standard of care applicable to that mental health professional, in the state in which the mental health professional is licensed.
I understand that the mental health professional may diagnose me with a mental or emotional disability.
I agree to be truthful in my interactions with the mental health professional as I would with any other health care provider.
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