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What is the reason for seeking care?

Select all that apply. This helps us understand what's bringing you to therapy and confirm fit before your consultation.

Life Transitions Anxiety and Stress Management Burnout and Overwhelm College Mental Health Academic and Career Concerns Self-Esteem and Confidence Relationship Challenges Trauma Other

What kind of care is being sought?

Let us know what type of support fits your needs.

Individual therapy for myself Support for a teen, I am the parent or guardian

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

This helps us understand your care history so we can provide informed, coordinated support from your first session.

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

Are you, or the person receiving care, currently having thoughts of harming yourself or someone else, or experiencing a mental health crisis?

Calvary De'Rosa Counseling and Consulting provides outpatient therapy by appointment. We are not a crisis service, and this form is not monitored continuously, so we cannot guarantee immediate support if you are in crisis right now. For medical emergencies, call 911. For immediate mental health crisis support, call or text 988 (Suicide and Crisis Lifeline), available 24 hours a day. Answering "Yes" below will not prevent your inquiry from being received, but please use the resources above first if you need support right away.

Yes No

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