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Bennett Center for Behavioral Health

Behavioral Health Form

If you are interested in therapy, please fill out the form below, or email us.​

 

If you do not receive a call within 48 hours, please contact the Bennett Center for Behavioral Health at 203-622-1881.

Multi-line address
Date of birth
Month
Day
Year
Have you ever been in therapy before?
Yes
No
What days of the week are you available? (check all that apply)
What time of the day can you meet? (check all that apply)
Are you currently seeing a psychiatrist for medication management?
Yes
No
Is this for a court order or forensic related matter?
Yes
No
Do you own a firearm?
Yes
No
Have you been hospitalized in the last 3 months?
Yes
No
Have you thought about harming yourself?
Yes
No
Have you thought about harming others?
Yes
No
Do you have any active substance abuse concerns, or sobriety for less than 3 months?
Yes
No
Are you requesting a specific therapist?
Yes
No
Are you open to teletherapy?
Yes
No
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