Vital Psychological Therapeutics, P.C.

Vital Psychological Therapeutics, P.C. Send Message

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Date of birth

Gender

State

Select the state you live in

Home Zip Code

Reason for care

What is the main reason you are seeking care?

Please check all that apply

Feeling that others are talking about you or TV/radio/online messages are about you Feeling you’re being spied on, followed, or harmed by specific people or groups Feeling like other people can tell what you’re thinking Feeling that some thoughts/impulses “aren’t really yours” or that your actions are controlled by an external force Feeling you have unique powers, skills, or special destiny Hearing voices that other people can't hear Having other unusual perceptual experiences (e.g., visual, tactile, olfactory) Having low motivation Having emotional or social difficulties (e.g., developing and/or maintaining relationships) Experiencing limited ability to enjoy activities Other difficulties/concerns (please describe in the box below)

I was given the following diagnosis by a mental health clinician:

Schizophrenia Schizoaffective Disorder Depression with Psychotic Symptoms Bipolar Disorder Postpartum Psychosis Delusional Disorder Brief Psychotic Disorder I'm not sure / I don't remember I was not diagnosed with any of the above

Administrative

Referral source

How did you find out about Vital Psychological Therapeutics?

Web search (e.g., Google, ChatGPT) Facebook Instagram Other Social Media A doctor or psychotherapist Family members, friends, or other people Another patient at Vital Psychological Therapeutics An online referral source (e.g., Psychology Today, Therapy Finder) Other

Client Preferences

Anything you’d like to ask or anything else you’d like us to know?

Limited to 600 characters

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.