Nightingale Cedar Falls Therapy Counseling Mental Health Psychiatry Psychiatrist

Potential Patient Screening Questionnaire

Please take a moment to fill out the form below. The form only needs to be completed once and will be automatically sent to our admin team.

First and Last Name

Phone

Birthday

Questionnaire Consent

I agree to the terms and conditions above.

Choose which service(s) you are interested in: Required

Therapy

Medication Management

Why are you seeking treatment?

Are you currently receiving care from a psychiatric provider? If so, please explain.

Is there anything else we need to know in order to assess your needs? (Eating Disorder, Mental Health issue not listed, thoughts of suicide)

Who referred you to our Clinic?

Thank you for your interest in becoming a patient at The Nightingale Center. Your form has been submitted.We will be in contact within a few business days.