Take this quick assessment!
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Question 1 of 13
Name
Question 2 of 13
Baby's birth date or due date
Question 3 of 13
Describe, in your own words, the struggles you are experiencing
Question 4 of 13
Please select any of the following symptoms you have recently experienced:
Agitation
Irritability
Inability to sit still
Constant worry
Racing thoughts
Confusion
Excessive concern about baby or own health
On high alert
Appetite changes
Difficulty falling or staying asleep
Persistent gloomy mood
Sadness
Crying
Mood swings
Low self-esteem
Feelings of guilt or shame
Loss of interest, joy, or pleasure
Poor concentration
Feelings of helplessness
Feelings of hopelessness
Feeling overwhelmed
Isolation or feelings of loneliness
Lack of feelings toward baby
Scary, worried, or intrusive thoughts
Thoughts of self-harm
Thoughts of harm toward baby
Paranoia
Hearing or seeing troublesome things
Question 5 of 13
What symptom is troubling you the most?
Question 6 of 13
How well are you currently functioning on a scale of 0-10 (0 being not well at all and 10 being perfectly fine)?
Question 7 of 13
Please describe your goals in seeking support.
Question 8 of 13
Do you have any prior experience with mental health issues, personally or in your family (anxiety, depression, etc.), or do you have a history of trauma?
Question 9 of 13
Have you previously experienced sensitivity to hormonal changes or do you have any endocrine dysfunction (thyroid disorder, etc.)?
Question 10 of 13
Contact Info (email & phone number)
Question 11 of 13
Location (City, State)
Question 12 of 13
What is your availability for appointments? (best days, times)
Question 13 of 13
How did you hear about us?