Cóndor Center Consultation Questionnaire
*I consent that CONDOR CENTER will review my answers so that I can schedule a phone consultation

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電子郵件 *
Name/ Nombre *
Phone Number/ Numero de teléfono *
Age/ Edad *
Are you seeking therapy for yourself or someone else? / ¿Busca terapia para uds o alguien mas? *
What service are you interested in?/ ¿Que tipo de terapia esta buscando? *
What language would you prefer for treatment?/ ¿En que idioma busca tratamiento? *
How do you wish to receive services?/ ¿Como prefiere recibir los servicios? *
What are presenting problems that are prompting you to seek therapy?/ ¿Cuales son los problemas que ocurren para querer buscar terapia? *
Do you have a history of suicidal thoughts or self harm? If yes, when was the last time?/ ¿Tiene o a tenido pensamientos de suicidio o de hacerse daño, cuando fue la ultima vez? *
Have you ever been hospitalized due to your mental health? If yes, please explain/ ¿Alguna vez a sido hospitalizado por su salud mental? Por favor de explicar la razon. *
How did you hear about CONDOR CENTER?/ ¿Como escucho de CONDOR CENTER? *
By completing and submitting this I understand:
-I am seeking service with CONDOR CENTER as a private practice client
-I will first have a phone consultation with the clinical director from the CONDOR CENTER team
-I will be able to ask a representative questions before deciding if I wish to start treatment and schedule an intake appointment with a provider from this private group practice

Please check the box below if you agree to the statement above: *
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系統會透過電子郵件將你的作答內容複本傳送到你所提供的地址。
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