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How We Treat
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What We Treat
Alcohol Addiction Treatment
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Cocaine Addiction Treatment
Heroin Addiction Treatment
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Prescription Drug Addiction Treatment
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Faith-Based Program
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First Responder Online Rehab
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Menu
Home
About
Who We Treat
College Students
Pregnant Women
Professionals
How We Treat
Virtual TF-CBT at Banyan Telehealth
What We Treat
Alcohol Addiction Treatment
Benzodiazepine Addiction Treatment
Cocaine Addiction Treatment
Heroin Addiction Treatment
Opioid Addiction Treatment
Prescription Drug Addiction Treatment
Programs
Faith-Based Program
Family Services
First Responder Online Rehab
Veterans Program
Veterans’ Family Therapy
Mental Health
Anxiety Treatment
Bipolar Disorder
Cognitive Behavioral Therapy
Co-Occurring Disorders
DBT Services
Depression Management
EMDR
OCD Treatment
PTSD Therapy
Schizophrenia
Telehealth Locations
Alaska
Alabama
California
Illinois
Delaware
Massachusetts
Mississippi
New Hampshire
Pennsylvania
Texas
Verify Insurance
We Have Beds Available! Call For Same Day Admission.
855-722-6926
Menu
Home
About
Who We Treat
College Students
Pregnant Women
Professionals
How We Treat
Virtual TF-CBT at Banyan Telehealth
What We Treat
Alcohol Addiction Treatment
Benzodiazepine Addiction Treatment
Cocaine Addiction Treatment
Heroin Addiction Treatment
Opioid Addiction Treatment
Prescription Drug Addiction Treatment
Programs
Faith-Based Program
Family Services
First Responder Online Rehab
Veterans Program
Veterans’ Family Therapy
Mental Health
Anxiety Treatment
Bipolar Disorder
Cognitive Behavioral Therapy
Co-Occurring Disorders
DBT Services
Depression Management
EMDR
OCD Treatment
PTSD Therapy
Schizophrenia
Telehealth Locations
Alaska
Alabama
California
Illinois
Delaware
Massachusetts
Mississippi
New Hampshire
Pennsylvania
Texas
Verify Insurance
Quick Assessment Form
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Unique Programs & Therapies Offered
Quick Assessment Form
Telehealth Intake Form
Why are you seeking therapy?
Depression
Anxiety
Trauma/PTSD/CPTSD
Mood Swings
Bipolar Disorder
Substance Use
Which substances are you struggling with?
Alcohol
Marijuana
Cocaine
Opiates (street or Rx)
Benzodiazepines
Other
Please list any additional substances not listed
When did you last use alcohol?
Have you ever received inpatient treatment for substance use or mental health disorder before?
No
Yes
If so, where did you attend treatment?
Are you currently experiencing any of the following? (check all that apply)
Hallucinations
Suicidal Thoughts
Homocidal Thoughts
Mood Swings
Depression
Irritability
Paranoia
Restlessness
Increased Sleep
Decreased Sleep
Anger
Trauma Symptoms (flashbacks, hypervigilance)
Have you ever experienced any of the following?
Suicidal Thoughts
Suicidal Plans
Suicide Attempt
When did you attempt to commit suicide?
Have you ever had thoughts about harming others?
No
Yes
Please explain
Have you ever made plans to harm others?
No
Yes
Please explain
Have you ever harmed others?
No
Yes
Please explain
Do you have any significant medical problems?
Are you taking any medications for a mental health diagnosis?
No
Yes
Name / Dose
Are you required to register as a sex offender?
No
Yes
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