Intake Form

First Name *

Email Address *

Phone Number

Date of Birth

What are the problems for which you are seeking help ?

Current Symptoms ( click all that apply )Racing thoughtsDepressed moodImpulsivitySleep pattern disturbanceAvoidanceExcessive worryForgetfulnessUnable to enjoy activitiesFatigueSuspiciousnessLoss of interestChange in appetiteAnxiety attacksExcessive guiltIncreased risky behaviorIncreased IrritabilityIncreased libidoHallucinationsExcessive energyDecreased libidoDecreased need for sleepCrying spellOthers

Downloadable DN Behavior Intake Form

At Day and Nite Behavioral Services, we provide compassionate, patient-centered care that respects individual needs and voices, fostering a safe and supportive path toward healing and growth.

Important Links

Home
About Us
Services
Contact us
Schedule Consultation

Services

Psychotherapy (Talk Therapy)
Psychiatric Services
Counseling Services
Support Groups
Crisis Intervention Services
View All Services

Facebook Twitter Youtube