Today's Date *

MM

DD

YYYY

Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Sex Assigned at Birth *

Male

Female

Gender Identity *

Male

Female

Marital Status *

Check all that apply.

Single

Married

Domestic Partnership

In a relationship

Separated

Divorced

Widowed

Employment Status *

Check all that apply.

Full time student

Part time student

Military

Unemployed

At home Mom/Dad

Retired/Pensioner

Receiving government assistance

Working less than 30 hours per week

Working 30+ hours per week

Have you ever received counseling in the past? *

no

yes

Ever received a formal psychological evaluation? *

no

yes

Have you used drugs in the past 5 years? *

no

yes

Do you ever think about physically harming yourself or committing suicide? *

no

yes

Do you currently experience these thoughts? *

no

yes

Ever think about physically harming other people? *

no

yes

Currently? *

no

yes

Do you currently feel threatened or in danger of being physically or emotionally harmed by another person? *

no

yes