Designed Health Options Admission Questionnaire Albuquerque, New Mexico

Name *

First

Last

Date of Birth

Home Phone

Mobile Phone & Text

Email

Preferred Communication?

What are your goals in this experience? (select 5)

Working through & learning from past experiences
Building self-confidence
Learning stablization/coping techniques
Developing self-control
Developing self-reliance
Developing a clearer identity of self
To face your fears
To get feedback
To learn a healthy thought process
To understand triggers
To find peace
To overcome obstacles
To share your story
To get some relief
To know yourself better
Alleviate emotional pain or confusion
To develop a more complete understanding of your issues
Foster a more accurate understanding of your past and what you want for your future
To be healthier physically
To feel more in control of my disease process
To feel that someone who cares about my health is truly listening to what I'm saying

Is your daily life being affected in any of the following ways? (select all that apply)

How much time are you willing to invest in achieving your goals?

Are you open to considering sessions virtually online through video conferencing?

Do you have a preferred appointment time frame or day(s)? (select all that apply)

Is there anything specific or in particular you would like us to know?