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FIyjXcJogxYAPNqDFYZtofK6ksTkk3tWj7z6NsQMAwAjkNuA32fCV4IYxwBYMsJ8DDB4KovoVmSzHZnvh2HuEPNCpBb3nkwVs85PIU8imEEBuXsJQz

CTSA New Patient Screening Questionnaire

Thank you for your interest in the CTSA. We offer diagnostic evaluation and outpatient treatment for obsessive compulsive disorder, posttraumatic stress disorder, and anxiety-related disorders. In order to be sure that we will be a good fit for treatment at our specialty clinic, we ask that you answer the following questions to the best of your ability. Once we have received your responses, we will be in touch to schedule an initial in-person evaluation or to provide you with appropriate referrals.

This questionnaire is hosted on a confidential server. The security of your information is of great importance to us.

**Please note that completion of this questionnaire is a prerequisite to being accepted as a new patient and does not guarantee that CTSA will provide therapy services for you or your child.**

Thank you!

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**

M-D-Y

Male

Female

Transgender

Something else

Prefer not to disclose

Gender Non-Conforming / Genderqueer

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M-D-Y

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.

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Yes

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I acknowledge that if two unmarried parents share legal custody, CTSA requires consent from both parents before starting treatment.

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Yes

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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:

-Aetna Student Health (ASH) for students of the University of Pennsylvania or Drexel Univeristy
OR
-Penn Behavioral Health (PBH) for employees of the University of Pennsylvania. PBH is the mental health coverage under PennCare and Aetna POS II plans for employees at UPenn.

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 PBH and ASH.

Please note: We do not accept Medicare or Medicaid.

Yes

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M-D-Y

Yes

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Yes

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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.

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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.

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Yes

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Online

Another mental health professional

Word of mouth

Flyer

Past patient

Don't know

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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

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Yes

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Standard outpatient (1-2 sessions per week)

Intensive outpatient (daily session for 3.5 weeks - $600/session)

Yes

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Self-guided web program

Therapist assisted web program

Mobile application

In Person

Telehealth

Telephone

Video

Yes

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I acknowledge that if the patient is 14 years or older, they are required by Pennsylvania law to consent to their own treatment.

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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.

Monday

Tuesday

Wednesday

Thursday

Friday

9 am - 11 am

11 am - 1 pm

1 pm - 3 pm

3 pm - 4 pm

Phone

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The response has now been removed for the last question for which you selected a value. You may now enter a new response for that question and continue the survey.