Request appointment | Nick Donahue LICSW PLLC.

What's bringing you in right now?

In a few sentences, what are you hoping to get help with?

Who is this appointment for?

Myself My child/dependent Someone else

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

What are you hoping to find support with in therapy? (Check all that apply)

Anxiety or chronic worry Relationships or dating Self-esteem or identity Substance use Stress or life transitions ADHD/attention/executive functioning Other

Please explain in more detail what you are seeking support with.

A few sentences is fine.

Limited to 600 characters

Have you experienced or received support for any of the following? (Check all that apply)

Currently in therapy In therapy in the past Currently taking psychiatric medication (including antidepressants, stimulants, etc.) Taken psychiatric medication in the past Hospitalized for mental health reasons currently or recently (in the last 12 months) Hospitalized for mental health reasons previously (longer than 1 year ago) Diagnosed neurological or psychiatric disorder Attempted suicide in the past None of the above

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