Assigned To* First Name* Last Name* Mobile Phone Preferred Name Date of Birth Pronouns Street City State Zip Code Primary Insurance Home Phone Email Secondary Insurance Medicare Select Value Yes No Medicare Enrollment Select Value Yes No Maybe Medicaid Select Value Yes No Custody Agreement Select Value Yes No Custody Agreement Details Teen Self Register Select Value Yes No Add Second Guardian Guardian1 First Name Guardian1 Last Name Guardian1 Relationship Select Value Parent/Legal Guardian Stepparent Other Relative Other Guardian1 Mobile Guardian1 Email Guardian2 First Name Guardian2 Last Name Guardian2 Relationship Select Value Parent/Legal Guardian Stepparent Other Relative Other Guardian2 Mobile Guardian2 Email Child Willingness Select Value Yes No Child Willingness Detail Parent Willingness Select Value Yes No Parent Willingness Detail PCP Select Value Yes No PCP Details Formal Diagnoses Select Value Yes No Formal Diagnoses Details Medication Select Value Yes No Medication Details Previous Providers Grade Select Value Pre-K Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th College/University Not currently enrolled 504 IEP Select Value Yes No 504 IEP Details School Attendance Select Value Yes No School Attendance Details Symptoms Anxiety disorders (fears worry nervousness) OCD or intrusive thoughts PANS or PANDAS PTSD or trauma Hoarding School anxiety or avoidance Selective mutism Young adult launch difficulties Hair pulling or skin picking (BFRBs) Body dysmorphic disorder (BDD) Tics or Tourettes Depression or mood disorders or grief Sleep disorders / insomnia Screen use problems Borderline personality disorder Difficulty controlling emotions Self-harm (historical or current) Suicidal thoughts (historical or current) Suicidal behavior (historical or current) Eating disorders (restriction purging bingeing) ARFID or selective eating Nutrition support or dietitian services Medication management or diagnostic evaluation Diabetes-related eating or mental health concerns I am not sure (please call 206-374-0109) Symptoms Details Intensity Select Value Standard Intensive Panic Symptoms Select Value Yes No Panic Symptoms Details Social Anxiety Symptoms Select Value Yes No Social Anxiety Symptoms Details General Anxiety Symptoms Select Value Yes No General Anxiety Symptoms Details Intrusive Thoughts Select Value Yes No Intrusive Thoughts Details BFRBs Select Value Yes No BFRBs Details Compulsive Actions Select Value Yes No Compulsive Actions Details Depressive Symptoms Select Value Yes No Depressive Symptoms Details Eating Problems Select Value Yes No Eating Problems Details Impulsive Behaviors Select Value Yes No Impulsive Behaviors Details Social Functioning Oppositionality Select Value Yes No Oppositionality Details Emotion Dysregulation Select Value Yes No Emotion Dysregulation Details Impulsive Behaviors DBT Select Value Yes No Impulsive Behaviors DBT Details Interpersonal Problems Select Value Yes No Interpersonal Problems Details Trauma History Select Value Yes No Trauma History Details Psychotic Symptoms Select Value Yes No Psychotic Symptoms Details Psychotic Symptoms Treatment Select Value Yes No Psychotic Symptoms Treatment Details Willingness Select Value Yes No Willingness Details Inhibiters to Treatment Select Value Yes No Inhibiters to Treatment Details Eating Problems DBT Select Value Yes No Eating Problems DBT Details Oppositionality DBT Select Value Yes No Oppositionality DBT Details Eating Medical Provider Select Value Yes No Eating Medical Provider Details Eating Concerns Eating Behaviors Length Height Weight Eating Behaviors Skipping meals or going long periods without eating Avoiding certain foods or food groups or textures or smells or tastes Eating large amounts of food and/or feeling out of control while eating Making yourself vomit after eating Laxative or diuretic or diet pill use Exercising primarily to influence appearance Limited interest in food or eating Selective or picky eating that causes problems or distress Other eating- or food-related concerns None of the above Other Eating Behaviors Weight and Shape Select Value Yes No Weight and Shape Details Weight Change Select Value Yes No Weight Change Details Medical Concerns Select Value Yes No Medical Concerns Details Eating Treatment Select Value Yes No Eating Treatment Details Emotional Control Select Value Yes No Emotional Control Details Psychiatry Services Select Value Yes No Psychiatry Treatment Medication Management Diagnostic Assessment Second Opinion Thought Problems Select Value Yes No Thought Problems Details Eating Problems Psych Select Value Yes No Eating Problems Psych Details Parental Advisor Select Value Yes No Parental Advisor Details Oppositionality Psych Select Value Yes No Oppositionality Psych Details Diabetes Impact Select Value Never Rarely Sometimes Often Always Diabetes Hospitalizations Select Value Yes No Blood Sugar High Select Value Never Rarely Sometimes Often Always Blood Sugar Low Select Value Never Rarely Sometimes Often Always Diabetes Weight or Shape Select Value Never Rarely Sometimes Often Always Diabetes Eating Select Value Never Rarely Sometimes Often Always Worry Diabetes Select Value Yes No Depressive Symptoms Diabetes Select Value Yes No Depressive Symptoms Diabetes Details Emotion Dysregulation Diabetes Select Value Yes No Emotion Dysregulation Diabetes Details Eating Pattern Select Value Never Rarely Sometimes Often Always Weight Feelings Select Value Never Rarely Sometimes Often Always Nutrition Goals Nutrition Provider Select Value Yes No Nutrition Provider Details Nutrition Diagnoses Select Value Yes No Nutrition Diagnoses Details Self-Harm Select Value Yes No Self-Harm Details Suicidality Select Value Yes No Suicidality Details Hospitalization Select Value Yes No Hospitalization Details Substance Use Select Value Yes No Substance Use Details Self-Reported Lead Source Select Value Advertisement Family Friend Submission Information Online Search Previous Client Provider Referral Word of Mouth Provider Referral Information Session Availability Morning (9 AM - 12 PM) Afternoon (12 PM - 2 PM) Late Afternoon (2 PM - 5 PM) Place of Service Preference Select Value In Person Telehealth Combination No Preference / Unsure Prefer In Person -- Willing Telehealth Prefer Telehealth -- Willing In Person Preferred Therapist Identities Difficult Therapist Identities Postdoctoral Fellow Select Value Yes No Practicum Student Select Value Yes No Submitter Submitter Relationship Select Value Self Parent/Legal Guardian Other Relative Friend Therapist or Medical Provider Other Prospective Client Select Value Myself (18+) Myself (Under 18) My child or teenager Couples Therapy My Client Contact Preference Phone Call Text Message Email Outreach Location Select Value Seattle Bellingham Salt Lake City Screened Online? SMS Opt In Treatment Program Select Value Child Anxiety Adult Anxiety Anxiety Intensive DBT Adolescent DBT Adult DBT Intensive Eating Disorders Psychiatry Full Name Insurance Card - Front Insurance card - Back 