Preferred Language*

Preferred Mode of Communication*

How did you hear about us?*

Do you have any health history?*

Have you ever been hospitalized due to a mental illness?*

Are you currently on any medication?*

Have you ever been to therapy before?*

Have you ever harmed yourself in the past?*

Have you ever harmed someone else in the past?*

Do you have any current thoughts of harming yourself?*

Do you have any current thoughts of harming others?*

Have you read and do you accept the terms and conditions prior to engaging in therapy?*

Have you read and do you accept the payment and cancellation policy prior to engaging in therapy?*

Do you consent to being treated by Oasis Health?*

Intended Service*

Date of Signing*