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Questions marked with a * are required Exit Survey
 
 
What insurance do you plan on using?
 
Aetna
 
Blue Cross / Blue Shield
 
United Healthcare
 
United Healthcare Oxford
 
Medicare
 
 
 
* What is your reason for visiting Neighborhood?
   
 
 
 
* Have you ever been diagnosed by a clinician? If so , please refer to question 4.
 
Yes
 
No
 
 
 
Please specify your diagnosis.
 
Depression
 
Anxiety
 
ADD/ADHD
 
OCD
 
PTSD

 
 
 
* Have you ever been hospitalized for mental health? If so, please provide date of hospitalization(s) and reason(s) for hospitalization(s).
   
 
 
 
* Have you ever had suicidal thoughts? If so, please specify.
   
 
 
 
Do you currently have suicidal thoughts or ideations?
 
Yes
 
No
 
 
 
Have you ever attempted suicide? If so, please specify.