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Referral Form

To make a referral, please fill out the information below. (Please note, self-referrals are accepted).

Client Information

Emergency Contact

In the past month has the client...

Felt down or depressed?
Felt less interested in doing things they normally like to do?
Experienced periods of excessive energy, mood swings, irritability, and/or loss of concentation?
Been worrying excessively about a number of things?
Felt very nervous, anxious, or suddely exprienced a lot of physcal symptoms (heart racing, sweating)?
Had a fear of losing control or "going crazy"?
Avoided social situations for fear of what othes might think or say?
Been afraid of leaving home, or being home alone?
Had repeated thoughts or images that are difficult to dismiss?
Felt compelled to complete certain behaviors repeatedly?
Been concerned about the use of alcohol or medication/drugs?
Had thoughts of self harm/suicide
Been having thoughts about the past, or feelings of reliving the past?
Felt disconnected from the body/out of body/dissociated
Being preoccupied with food, weight, or body image?
Had a significant loss or other significant stressor? (Please Describe)
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Vital Minds Psychotherapy
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