Learning to Achieve Wellness Assessment

Over the last two weeks,

How often did you feel down, depressed or hopeless?

Not at all

Several days

More than half the days

Nearly every day

Over the last two weeks,

How often did you have trouble falling or staying asleep or have been sleeping too much?

Not at all

Several days

More than half the days

Nearly every day

Over the last two weeks,

How often did you feel tired or have little energy?

Not at all

Several days

More than half the days

Nearly every day

Over the last two weeks,

How often did you have a poor appetite or eat too much?

Not at all

Several days

More than half the days

Nearly every day

Over the last two weeks,

How often did you feel bad about yourself, that you are a failure, or that you have let yourself or your family down?

Not at all

Several days

More than half the days

Nearly every day

Over the last two weeks,

How often have you had trouble concentrating on things such as reading the newspaper or watching television?

Not at all

Several days

More than half the days

Nearly every day

Over the last two weeks,

How often have you had thoughts that you would be better off dead or had thoughts of hurting yourself?

Not at all

Several days

More than half the days

Nearly every day

Over the last two weeks,

How often have you been moving or speaking so slowly that other people could have noticed or, on the opposite end, feeling so fidgety or restless that you’ve been moving around a lot more than usual?

Not at all

Several days

More than half the days

Nearly every day

What's your name & best email address?

We'll need this to send you your assessment results

Full Name

Please specify an answer

Your email address

Please specify an answer

Your Depression Score:

@Q1+@Q2+@Q3+@Q4+@Q5+@Q6+@Q7+@Q8+@Q9

Which location is best for you?

What service are you inquiring about?

TMS Therapy

Spravato Therapy

Which insurance do you have?

What's your best phone number?

Phone number

Please enter a valid phone number

By providing my information, I agree to be contacted by a member of the Patient Care Team. Your information is secure. We do not rent or sell your data.

Goals

Health

Household

Offers

I've sent you a text message with a verification code

Please enter it below to get a Priority status

4-digit code

Please enter the verification code sent to your phone number

By clicking the “Confirm My Phone” button, I expressly consent via electronic signature to receive marketing communications regarding mentalh health services via an automated telephone dialing system and/or pre-recorded calls, text messages, and/or emails from Learning to Achieve Wellness at the phone number and/or email provided above, including wireless numbers, if applicable, even if I have previously registered the provided number on the Do Not Call Registry.

Consent is not a condition of purchase and may be revoked at any time.

Why are we asking for your phone?

Life insurance pricing is incredibly personal, and rates are based on your unique data.

We try to make this process easy. By answering a few questions to verify your identity, we'll be able to provide you with more accurate rates and introduce you to better and more providers.

Thank you!

Next step:

A member of our team will be in touch with you shortly. If you’d like to speak with one of our medical providers sooner to review the results of you PHQ9 you can call or text us.

Over the last two weeks,

How often did you have little interest or pleasure in doing things?

Over the last two weeks,

How often did you feel down, depressed or hopeless?

Over the last two weeks,

How often did you have trouble falling or staying asleep or have been sleeping too much?

Over the last two weeks,

How often did you feel tired or have little energy?

Over the last two weeks,

How often did you have a poor appetite or eat too much?

Over the last two weeks,

How often did you feel bad about yourself, that you are a failure, or that you have let yourself or your family down?

Over the last two weeks,

How often have you had trouble concentrating on things such as reading the newspaper or watching television?

Over the last two weeks,

How often have you had thoughts that you would be better off dead or had thoughts of hurting yourself?

Over the last two weeks,

How often have you been moving or speaking so slowly that other people could have noticed or, on the opposite end, feeling so fidgety or restless that you’ve been moving around a lot more than usual?

What's your name & best email address?

Which location is best for you?

What service are you inquiring about?

Which insurance do you have?

What's your best phone number?

I've sent you a text message with a verification code

Consent is not a condition of purchase and may be revoked at any time.

Thank you!

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