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Pre-Assessment Questionnaire

Having a “Good Fit” between patient and provider is critical for success!  

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In order to determine if we are a good fit, we ask that you complete the following form. 

Is Totality Mindcare a Good Fit for Me?

Thank you for considering Totality Mindcare for your mental health needs. 


Totality Mindcare is a small, solo, outpatient private practice. Thus, there is a limited number of new patients accepted based on the current resources, time and treatment strategies available. This questionnaire is designed to help Totality Mindcare determine whether our services align with your current mental health needs and if we would be a good fit in assisting you with your treatment goals. We appreciate you taking the time to complete it.


This information is held to the same standards of confidentiality as our services.


If this is a life-threatening situation or you have an emergency, please call 9-1-1 or go to the nearest emergency room.

Who is completing this form
Birthday
Month
Day
Year
Which one of our service states does Patient reside in?
New Jersey
Massachusetts
Connecticut
How did you hear about us?
Do you plan to use insurance coverage to pay for services?
Yes
No
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