Please enable JavaScript in your browser to complete this form.Name *FirstLastDate / Time *DateTimeYour Email *Email to receive a copyEmail to receive a copyTherapist *Aaron YearwoodBrittany PreslarHaleigh KauffmannKirsten ColeMaria ChaseMarina SkrabalakRebecca WojciechowskiShannon MulliganTaylor KrachtTrent MorrowUyen DinhFrequency of symptoms . Selected Value: 0Number of times you have felt strong emotions (anger, worry, anxiety, sadness).Intensity of symptoms from 1-10 with 10 being the worst. Selected Value: 0Duration of symptoms in minutes. *510203060Which symptoms are you identifying. *AnxietyDepressionEmotional regulation (anger)General stressDaily average amount of sleep you have gotten in hours. *678910Daily average screen time this week i.e. phone, video games, YouTube in hours. *02468Daily average amount of exercise you have gotten in minutes. *020204560Number of times in conflict (For couples only)Zero1-3 times4-55 or moreOne thing you learned in session and will practice. *Homework/Treatment goal between sessions. *ToolsComments/ConcernsSubmit
