If you feel that you are a danger to yourself or to others, please immediately discontinue this screening tool and call 911 or go to your nearest emergency room. If you are struggling with suicidal thoughts or feelings, you can contact the National Suicide Prevention Lifeline (which provides 24/7, free, confidential support) at 1-800-273-TALK (8255) or the Pennsylvania Hospital Crisis Response Center at 215-829-5433. Because CTSA is a small outpatient specialty clinic and our staff is not on call, we are unable to provide emergency/crisis services. Information entered into this questionnaire is typically reviewed in the next 3-4 business days.
**YOU MUST CLICK SUBMIT AT THE END OF THIS QUESTIONNAIRE OR YOUR RESPONSES WILL NOT BE RECORDED**
Date of Inquiry
* must provide value
Today M-D-Y
Are you looking for services for yourself or someone else?
* must provide value
I am looking for services for myself I am looking for services for another adult (over the age of 18) I am looking for services for a minor (under the age of 18)
First name of person filling out this form
* must provide value
Last name of person filling out this form
* must provide value
Date of Birth of person filling out this form
* must provide value
Today M-D-Y
What is your relationship to the patient?
* must provide value
Mother Father Grandparent Guardian Other
Other relationship:
* must provide value
Patient's name
* must provide value
Patient's Gender Identity
* must provide value
Male
Female
Transgender
Something else
Prefer not to disclose
Gender Non-Conforming / Genderqueer
Please specify Gender Identity
* must provide value
Patient's Date of Birth
* must provide value
Today M-D-Y (if you are the patient, please re-enter your date of birth here)
Patient's Age
(If you are 14 or younger, you must have a parent complete this form with you)
* must provide value
View equation
In the state of Pennsylvania, adolescents ages 14-18 can consent to outpatient mental health examination and treatment for him/herself without parental consent. Parents can also consent on behalf of the adolescent, without the adolescent's consent. Neither the parent nor the adolescent may override the other's consent. (Age of Consent to Mental Health Treatment in Pennsylvania Effects of Act No. 2004-147; Senate Bill No. 137, Session of 2004). Therefore, either a parent or adolescent (14+) can initiate the treatment process. Consent for evaluation/treatment from one or both parties (parents or teen) will be collected before the evaluation.
Patient's address
* must provide value
please include zip code
Do both parents share legal custody of the patient?
* must provide value
Yes
No
What is the relationship status of the child's legal guardians?
* must provide value
Married Never married Divorced Separated Other
Please specify relationship status:
* must provide value
I acknowledge that if two unmarried parents share legal custody, CTSA requires consent from both parents before starting treatment.
Best Phone Number
* must provide value
By entering your phone number, you agree to be contacted by CTSA staff via phone. Prefer not to be contacted by phone? Type (999) 999-9999
Do you consent to CTSA leaving you a voicemail stating that we are calling from the University of Pennsylvania?
* must provide value
Yes
No
Best Email Address
* must provide value
By entering your email address, you agree to be contacted by CTSA staff via email. Prefer not to be contacted by email? Type noemail@donotuse.com
Please note that if you do not input an email address and/or phone number, we will be unable to follow up on this questionnaire and you will not be contacted by CTSA.
CTSA accepts two forms of insurance:
Insurances offered through Penn Care PPO for University of Pennsylvania Health System employees
All Aetna insurance plans, including for University of Pennsylvania employees and post docs
In the case of any other form of insurance, we are a self-pay clinic, and can provide you with billing statements at the end of each appointment which you may submit to your insurance company for potential out-of-network reimbursement. Our clinic does not have direct contact with any insurance companies other than those listed above.
Please note: We do not accept Medicare or Medicaid.
What type of insurance does the patient have?
* must provide value
Insurance through an employee of University of Pennsylvania or University of Pennsylvania Health System Insurance through student affiliation with the University of Pennsylvania Other insurance (insurance is not provided by the University of Pennsylvania) Uninsured Aetna
Please specify the patient's current insurance plan.
* must provide value
University of Pennsylvania PennCare (Independence Blue Cross) Aetna POS II Aetna Student Health (for students of UPenn and Drexel ONLY) Other
If other, please specify
* must provide value
What is the ID number on the patient's insurance card?
* must provide value
Is the patient the subscriber?
* must provide value
Yes
No
Please enter the first and last name of the subscriber and the patient's relationship to them.
* must provide value
Please enter the subscriber's date of birth.
* must provide value
Today M-D-Y
Is this the patient's only form of insurance?
* must provide value
Yes
No
Is Aetna Student Health the patient's only insurance provider?
* must provide value
Yes
No
Please list other active insurance plans and which plan the patient has had longest.
* must provide value
Please specify the patient's insurance plan.
* must provide value
There are 3 types of therapists in our group:
-Licensed Psychologists ($600/initial evaluation; $500/90-minute therapy session; $250/50-minute therapy session)
-Postdoctoral Fellows ($400/initial evaluation; $350/90-minute therapy session; $175/50-minute therapy session)
-Doctoral Student (Masters-Level) Clinicians ($100/initial evaluation; $100/90-minute therapy session; $50/50-minute therapy session) *Please note: Doctoral Student Clinicians typically only see patients 18 years of age or older*
The main differences are:
1) the level of certification of the provider (important mainly for insurance reimbursement)
2) the cost (per hour) of services.
All of our therapists have specialty training in Cognitive Behavioral Therapy and experience in providing state-of-the-art treatment for OCD, PTSD, Trichotillomania, Anxiety and related disorders in children, adolescents, and adults. All would provide evidence-based treatment that is specific to the presenting concerns. Our Doctoral Student Clinicians have extensive training and are closely supervised by licensed psychologists. We are confident that all of our therapists would provide excellent treatment.
Licensed Psychologists ($600/initial evaluation; $500/90-minute therapy session; $250/50-minute therapy session)
Postdoctoral Fellows ($400/initial evaluation; $350/90-minute therapy session; $175/50-minute therapy session)
Doctoral Student (Masters-Level) Clinicians ($100/initial evaluation; $100/90-minute therapy session; $50/50-minute therapy session)
The provider with the soonest availability
I acknowledge that the clinical hours of CTSA are 9:00 am to 5:00 pm Monday - Friday, and that treatment sessions take place within those hours.
I acknowledge that, following the evaluation, there is a waitlist to begin treatment. The length of the waitlist depends on: 1) your flexibility in terms of days/times for appointments, and 2) the provider or level of provider best suited to provide treatment, which is based on your preferences, therapist/client availability, and clinical judgment about best fit based during the evaluation. At present, our estimate of wait times is 4-6 weeks after the initial evaluation.
Were you referred to the center via COBALT?
* must provide value
Yes
No
How did you hear about CTSA?
* must provide value
Online
Another mental health professional
Word of mouth
Flyer
Past patient
Don't know
What is the primary concern that brings you to CTSA?
* must provide value
Does the patient have any of these concerns or diagnoses (check all that apply)
* must provide value
Attentional difficulties or Attention Deficit/Hyperactivity Disorder (ADHD)
Autism Spectrum Disorder (ASD) or Developmental Disability
Avoidant/Restrictive Food Intake Disorder (ARFID) or Picky Eating
Excoriation Disorder or Skin Picking
General Anxiety or Generalized Anxiety Disorder (GAD)
Mood Concerns (such as Depression or Bipolar Disorder)
Obsessive Compulsive Disorder (OCD)
Defiant Behavior or Oppositional Defiant Disorder (ODD)
Panic Attacks or Panic Disorder
Posttraumatic Stress Disorder (PTSD)
Selective Mutism
Separation Anxiety
Specific Phobia
Social Anxiety or Social Phobia
Tics
Tourette's Syndrome
Trichotillomania or Hair Pulling
Sleep-Related Issues or Disorders
Substace Use Related Difficulties
Eating Disorder (anorexia, bulimia, binge-eating)
Psychosis-Related Difficulties
Other
Other concerns or diagnoses (not listed above)
If the patient has any formal diagnoses, please list them with the name of the doctor who made the diagnosis and the approximate date of diagnosis.
Is the patient taking any medications?
* must provide value
Yes
No
Please list the medication names, dosage, and approximate date the patient started
* must provide value
Are you (or the person you are filling this form out for) motivated to participate in treatment?
* must provide value
Yes No Other
Motivation elaboration:
* must provide value
What forms of treatment are you interested in receiving?
Standard outpatient (1-2 sessions per week)
Intensive outpatient (daily session for 3.5 weeks - $600/session)
If available in the future, would you be interested in internet-based therapy services?
Yes
No
Which services would you be interested in (select all that apply)?
Self-guided web program
Therapist assisted web program
Mobile application
Which treatment options you would be comfortable with?Please note that the prefered treatment option cannot be guranteed
* must provide value
In Person
Telehealth
Which treatment modality would you prefer if telehealth is available?
* must provide value
Telephone
Video
If available, would you be interested in group treatment options?
Yes
No
I acknowledge that if the patient is 14 years or older, they are required by Pennsylvania law to consent to their own treatment.
Thank you for completing this screening questionnaire.
When you have finished answering all questions, please be sure to select "Submit" below in order to save your responses and have them submitted for review by the CTSA intake team.
If you have not answered all required questions, you will be prompted to finish the questionnaire. Please note that unfinished questionnaires can not be reviewed.
In 3-4 business days after you submit the questionnaire (depending on your availability), you will receive a call from an intake coordinator at CTSA to complete a 10-15 minute phone screen. The phone screen must be completed before an evaluation appointment can be scheduled. If the patient is 18 years of age or older, they must be present at the time of the phone screen. From the questions below, please select days and times that you are available for us to contact you and/or the patient to complete the phone screen.
Please select the days when you and/or the patient are available to complete the phone screen.
* must provide value
Monday
Tuesday
Wednesday
Thursday
Friday
Please select the times when you and/or the patient are able to complete the phone screen.
* must provide value
9 am - 11 am
11 am - 1 pm
1 pm - 3 pm
3 pm - 4 pm
Would you prefer to be contacted by email or phone?
* must provide value
Email
Phone
Please note specific requests with regard to the time of the phone screen (if any).
*We may not be able to accommodate all requests.*
**YOU MUST CLICK SUBMIT OR YOUR RESPONSES WILL NOT BE RECORDED**