Request appointment | Happy Human Healthcare, LLC

What symptoms are you having that make you want to see someone?

Please check anything you have had problems with in the last year

Anxiety, worry, panic Attentional difficulties (ADHD) Bipolar, mania Depression, sadness, lack of interest Obsessive compulsive, repeat/intrusive thoughts or behaviors, OCD Substance use or addiction Suicidal thoughts Trauma, PTSD Seeing or hearing things other people don't Eating symptoms like restricting, binge eating, or throwing up after eating Other - please write in below

What kind of care do you need?

Check all that apply

Medication management Neuropsychiatric testing for unsure previous diagnosis Court ordered (required by a judge) Evaluation and diagnosis for symptoms Weekly therapy

Please share your past history of diagnosis and treatment

All answers are kept confidential, even if our clinic is not the best fit

In therapy now In therapy in the past Taking mental health medication now Taken mental health medication in the past Hospitalized for mental health reasons in the last year Suicide attempt in the last 5 years Prepared for suicide attempt in the last year - researched, made a plan, or gathered materials Known neurologic or genetic disorder or traumatic brain injury (TBI) None of these apply

Have you struggled with substance use or addiction?

Our clinic does not currently have the resources needed to treat substance use, but we can give you referrals.

Yes, currently with nicotine or cannabis Yes, currently with opiates, alcohol, stimulants, prescription pills, or other recreational substances Yes, but not in the last year No

Are you taking any controlled substances like opiate pain medications, benzodiazepines, stimulant medications, or sleep medicines?

These would be medicines that you are required to show your ID to pick up from the pharmacy. If yes, please list. If no, write none.

Limited to 600 characters

Is there anything else we should know or questions you have?

For example: a problem not listed in the form above, who referred you, or a question that the provider can answer on the patient portal. If no other information, you can write none.

Limited to 600 characters

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