About Us
Services & Programs
Community Resources
Make a Referral
We Have Some Questions For You!
Email
Your name (First, Middle Initial, Last)
Phone number
Back
Next
What is your race?
American Indian or Alaska Native
Hispanic or Latino
White
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Back
Next
Date of birth
What is your last known address?
Do you have physical ID?
Yes
No
Back
Next
SSN
Medicade # (if you have it)
Back
Next
Who is your insurance carrier?
Aetna
Sentara
Humana
United
ANTHEM - 23 HR
Other...
Back
Next
What is your current housing situation?
Homeless
Stable and living on own
Shelter
Staying with friends
Back
Next
What is the exact location of where you need to be picked up?
Is this a walk in appointment?
Yes
No
Where you referred by another provider?
Yes
No
Back
Next
Will you be going back to the referring agency, or continuing step down services with Decide to Believe?
Returning to referring agency
Continuing with Decide to Believe
Do you have transportation to get to our office, or will you need a ride?
I have transportation
I will need a ride
Are you currently receiving mental health skill building services?
Yes
No
Back
Next
Reason for appointment? (Select all that apply)
Aggression (physical/fighting)
Homicidal ideation
Verbal aggression (Threats/profanity)
Substance abuse
Disrespectful/Oppositional
Depressed mood
Interpersonal Skills
Problems with peers
Promiscuity
Social skills deficits
Disruptive behavior
Extreme hyperactivity
Inattention
Isolative behavior
Property destruction
Back
Next
What is your current crisis? What has been going on in the last 3 days?
Do you have a history of drug use?
Yes
No
Have your recently used any drugs, are you currently intoxicated?
Back
Next
Have you been thinking about hurting yourself or someone else?
Are you having trouble sleeping, eating, or taking care of yourself?
Have you ever had crisis services before? If yes, where and when?
Back
Next
If you don’t get help today, do you feel like things will get worse, such as the need to go to the hospital?
Yes
No
Have your recently used any drugs, are you currently intoxicated?
Back
Next
You’ve completed our survey, thank you!
Return Home
Oops! Something went wrong while submitting the form.
