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Darlene Brace

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Reason for care

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1 Appointment info

2 Prescreener

Reason for care

3 Contact information

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

What kind of care is being sought?

Individual Psychotherapy Relationship Counseling (couples/poly relationship work) Family Therapy Not sure

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Are there any circumstances that require immediate attention?

( e.g. new diagnosis, changes in health status, presence/absence of family members or partner(s), newly sober, other health illnesses, Addictions, Trauma, feeling suicidal, legal mandate)

What do you want to get out of coming to receive our support services. , or what are your goals?

On a scale of 1 -10 (1= Not Ready to Commit; 10 Fully Committed), how ready are you to commit to ongoing counseling for 6 months?

 What other support services do you receive currently? Mental health/ addiction counseling? If yes, with whom?

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

Darlene Brace

970.363.4277 |

Denver Colorado

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THE CLIENT PORTAL IS NOT TO BE USED FOR EMERGENCY SITUATIONS. IF YOU OR OTHERS ARE IN IMMEDIATE DANGER OR EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.