Request appointment | Mending the Mother Therapy and Wellness

Mending the Mother Therapy and Wellness

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Reason for care

Select date & time

1 Appointment info

2 Prescreener

Reason for care

3 Contact information

What is the reason for seeking care?

Anxiety/Overwhelm Attentional difficulties/ADHD/Executive Functioning Burnout/Mental Load Depression/Low Mood Grief/Loss Relationship issues Substance use Trauma Identify Transitions Pregnancy or Postpartum Mental Health Parenting Concerns Other

What kind of care is being sought?

Individual Psychotherapy Couples Counseling Coaching Not sure Other

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

Perinatal Care

Are you currently pregnant, trying to get pregnant, or within the first year of having a child?

Yes, currently pregnant Yes, within the first year postpartum Yes, trying to get pregnant No Not Applicable

Are you currently experiencing thoughts of suicide or thoughts of ending your life?

No Yes, but I do not have a plan or intention to act on these thoughts Yes, and I have considered how I might act on these thoughts I would prefer to discuss this directly with the therapist

Have you had a suicide attempt or psychiatric hospitalization within the past year?

No Yes

Are you currently experiencing any of the following?

Thoughts of harming someone else Hearing or seeing things that others do not Significant difficulty distinguishing what is real from what is not Severe difficulty sleeping for multiple nights Substance use that is significantly interfering with daily functioning None of the above I would prefer to discuss this directly with the therapist

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

Mending the Mother Therapy and Wellness

470.774.2526 |

Higganum

Main Location

Higganum, CT 06441-4392

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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.