Home » Intensive CBT Screening Form

Intensive CBT Screening Form

Confidential Patient Form

If you are interested obtaining intensive cognitive-behavioral treatment from the OCD Resource Center of Florida, please fill out the following screening form and send it to the Center. We will be back in touch with you to answer any questions you may have.

Please answer the following questions as best as you can. Your responses are completely confidential.

Your name:	First name & last initial only!
Phone number:
E-mail address:
Email will not be used for any other purpose than to communicate directly to you about treatment!
How to contact you:
Select intensive program:

Please list your current diagnosis, and any other diagnoses you have received.

What are your specific symptoms at the present time?

What is the effect of these symptoms on your daily functioning? Your job? Your family? Your relationship(s)?

When did you first notice these symptoms?

What sort of psychological treatment have you had for this disorder in the past? Has that treatment helped you?

Are you presently on medication for your disorder/anxiety? If so, what psychiatric medications you are presently on?