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 you should receive a confirmation email once the form is submitted. Please check junk/spam if you do not find it.

First and Last Name

Phone

Date of birth required

Questionnaire Consent

I agree to the terms and conditions above.

I am interested in Therapy Services.

I am interested in Medication Managment Services with Dr. Jenna Berenzen.

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?