Self-Check Questionnaire

Please fill out the form as completely and accurately as possible as all the information is important in determining effective strategies for your therapy program.


Step 1 of 6 - Patient Information


This is a safe, easy way to learn whether stress and depression might be affecting you and how you can receive support through our Military and First Responder Program.

This form is intended for the patient and their immediate family. Using this service is completely voluntary, anonymous and confidential. No information will be shared with the with your employer.

This is not an emergency response system or crisis intervention service. If you have recently thought about suicide, or are currently thinking about suicide, please call 911.


What happens next?

Our Medical Team will review your Questionnaire and post a personal response to you on this secure website. The response will include information, recommendations, and options for next steps.

You decide what's next. You'll have the option of communicating with our Medical Team through the platform, on the phone or in person. Or, you can decide to do nothing further at this time.

It's up to you. No follow-up services will be provided unless requested.


You'll have to of providing your contact information on your Questionnaire. Your email address will be HIPPA compliant system and will not be revealed to anyone, including the counselor. As further protection, you may wish to set up a new email account (e.g. gmail, yahoo, aol) that does not contain any part of your first or last name. If you don't give an email address, at the completion of the Self-Check Questionnaire you'll be told when to return to this website to get the counselor's response.

Questions? Contact Us at 312-554-5013 or Continue below.