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Anxiety Attention/concentration difficulties Depression Grief Relationship issues Trauma Self-esteem issues Other (briefly describe below)

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What mental health treatment if any, have you done in the past?

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In therapy now In therapy in the past Hospitalized for mental health reasons now or within the last six months Hospitalized for mental health reasons in the past Been in/completed substance use treatment in the past Been in/completed substance use treatment in the last six months None of these apply (I've never had mental health treatment before) Other (briefly describe below)

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