Congratulations on taking the first step towards wellness!
To schedule your first session please fill out this short 5-minute questionnaire.
Start
Step
1
of
10
10%
Disclaimer
(Required)
I am not in crisis or an emergency and can wait up to 72 hours for a response.
If you or someone you know is in a mental health crisis, please call or text 988, or chat 988lifeline.org to reach the Suicide & Crisis Prevention Lifeline. If this is a life-threatening emergency, please go to the nearest emergency room or call 911.
What's the triggering event that lead you to seek professional help? (be specific please)
(Required)
How much is the reason you are seeking services negatively impacting your life?
(Required)
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Self-Awareness and Management
Socially with Friends and /or Familial Relationships
Professionally
Sense of Connection and Purpose
Have you ever received psychological/addiction treatment?
(Required)
Individual/couples/family therapy
Intensive Outpatient Treatment
Residential/Inpatient
No previous treatment
Are you open to incorporating a loved one in your treatment
Yes
No
Are you willing to make significant changes in your lifestyle
Yes
No
Are you a Nevada resident?
(Required)
Yes
No
Full Name
(Required)
First
Last
Best Phone Number
(Required)
Primary Email
(Required)
Enter Email
Confirm Email
Consent
I agree to be added to the POJ Wellness email newsletter which send out minimal and pertinent information.
Δ
0% Completed!
Previous
Next
