Request appointment | Mindful Growth Collective

Mindful Growth Collective

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Reason for care

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1 Appointment info

2 Prescreener

Reason for care

3 Contact information

What is the reason for seeking care?

Anxiety ADHD Autism Depression Grief Relationship issues Substance use Trauma Life Transition / Adjustment Personal Growth Spirituality Other

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Please explain circumstances for seeking treatment.

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We need to ask questions regarding your current safety and stability. By clicking yes you consent to answering these questions truthfully.

Yes

Are you currently experiencing thoughts of suicide or thoughts of harming yourself or others?

Yes No

Do you currently have any intent or plans to end your life?

Yes No

Have you had past suicide attempts or mental health-related hospitalizations?

Yes No

Are there any current behaviors that feel unsafe or out of control?

Yes No

Are you experiencing symptoms of psychosis (hallucinations, delusions, paranoia, etc.)?

Yes Not currently but in the past No

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

Mindful Growth Collective

541.414.6989 |

Phoenix Oregon

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THE CLIENT PORTAL IS NOT TO BE USED FOR EMERGENCY SITUATIONS. IF YOU OR OTHERS ARE IN IMMEDIATE DANGER OR EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.