Questionnaire Step 1 of 13 7% EmailThis field is for validation purposes and should be left unchanged.Please fill out this brief questionnaire to help us determine your needs and eligibility for teletherapy services. All of your answers will remain secure and confidential.First Name*Last Name*Email* State of Residency*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Are you 12 years of age or older?* Yes No You are not eligible for BlueBird Teleshrink services, as you must be at least 12 years old. Have you ever been in mental health counseling or therapy?* Yes No When was the last time you were hospitalized for mental illness?* Never Less than a month ago 1-3 months ago Over 3 months ago Over a year ago When was the last time you thought about or tried hurting yourself?* Never Less than a month ago 1-3 months ago Over 3 months ago Over a year ago When was the last time you tried hurting someone else?* Never Less than a month ago 1-3 months ago Over 3 months ago Over a year ago Are you currently in a physically abusive/violent relationship?* Yes No How often do you drink alcohol?* Never Once a month or less 2 to 4 times a month 2 to 3 times a week 4 or more times a week How many drinks containing alcohol do you have on a typical day when you are drinking?* Never 1 or 2 3 or 4 5 or 6 7 or 9 10 or more Do you currently use drugs other than those required for medical reasons?* Yes No Do you currently use marijuana without a prescription?* Yes No When was the last time you had a plan for suicide?* Never Less than a month ago 1-3 months ago Over 3 months ago Over a year ago Briefly state why you are seeking help:* Δ If you or another individual is in need of immediate assistance please do not use this site.For immediate help please use these Resources.
