Please enable JavaScript in your browser to complete this form.Name *FirstLastDate *Email *Therapist *Trent MorrowImani CrawfordSade MassiahShannon SmithKirsten ColeTaylor KrachtLydia GrierWhich symptom are you identifying *AnxietyDepressionEmotional RegulationOtherFrequency of symptoms in the past 48 hours. Selected Value: 0Intensity of symptoms from 1-10 with 10 being the worst Selected Value: 0Duration of symptoms *0-5 minutes5-20 minutes20-40 minutes40 or more minutesSleep6 hours or less6-8 hours8 or more hoursVideo Games/Social Media/YouTube time2 hours or less2-4 hours4 or more hoursComments/ConcernsSubmit
