Name *

First Name

Last Name

Phone *

(###)

###

####

SMS/Text Message Agreement *

Message frequency varies and may include [e.g., appointment reminders, scheduling options, onboarding instructions, etc.] Message and data rates may apply. Opt-out at any time by replying 'STOP.' For help, text "HELP."

Yes, I agree to receive text messages from Seaside Mental Health, LLC at the phone number listed above.

No, I do not want to receive text messages from Seaside Mental Health, LLC.

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Treatment within the past six months *

Please check all that apply

Therapy Treatment

In-patient Psychiatric Hospitalization

Residential Treatment

Partial Hospital Program (PHP)

School 504 Plan or IEP

Intensive Outpatient Treatment (IOP)

Medication Management

None of the above

Current symptoms *

Please check all that apply

Anxiety

Depression

Self-Injury

Attention or Concentration Problems

Suicidal Thoughts

Substance Abuse

Violent or Aggressive Behavior

Impulsivity

Sleeping Difficulties

Eating Problems