Request appointment | Jillian Lee Counseling, PLLC

Jillian Lee Counseling, PLLC

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Reason for care

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Important Notice: This screening form is for administrative routing purposes only and is not monitored 24/7. Submission of this form does not establish a therapist-client relationship. This practice does not provide crisis intervention services. If you are experiencing a mental health emergency, please immediately call 911, go to your nearest emergency room, or call/text the Suicide & Crisis Lifeline at 988.

Please check the following below to confirm you have read the important notice.

What are you seeking treatment for at this time?

Women's Issues Anxiety Trauma/PTSD Religious Trauma Stress/Burnout Attachment and Relationship Issues Depression Other

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Our practice provides standard, weekly or bi-weekly outpatient counseling by appointment. Are you currently seeking a higher frequency of care, intensive outpatient (IOP/PHP) programming, or a setting with 24/7 crisis support?

Yes No

Have you required a hospital stay, residential treatment, or emergency psychiatric evaluation for any mental health concern within the last 6 months?

Yes No

Please share a little about why you are seeking treatment at this time.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

Jillian Lee Counseling, PLLC

360.233.2934 |

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THE CLIENT PORTAL IS NOT TO BE USED FOR EMERGENCY SITUATIONS. IF YOU OR OTHERS ARE IN IMMEDIATE DANGER OR EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.