Do you frequently have suicidal thoughts or harm yourself in non-suicidal ways?

Yes

No

Have you tried working with an outpatient doctor or therapist and find that is isn't enough address your struggles?

Yes

No

Were you recently discharged from an emergency room for suicidality and feel you need more support or therapy?

Yes

No

Were you recently discharged from a residential treatment center and want to continue your personal recovery journey?

Yes

No

Do you have addictive behavior keeping you from approaching your life goals?

Yes

No

Do you want to remain in an independent living situation while experiencing an intensive level of therapy?

Yes

No

Would you like your partner and family members to participate in your treatment?

Yes

No

Do you feel you need more coping skills for your stress, anxiety, addiction or depression?

Yes

No

Would you like to work with skilled clinicians to craft a treatment plan that's tailored to your needs?

Yes

No

Are you willing to practice new skills and techniques in a supportive community?

Yes

No

Name *

First Name

Last Name

Mobile/Phone

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