Safety Screening Questions

Thanks so much for your interest in our counseling and coaching sessions!

Before we can schedule your session(s), we need to ask a few safety questions to make sure that we are equipped to properly support you and/or your family.

Once completed you will be directed to the intake questionnaire and payment form.

Thank you!

Safety Screening Questions:

Please answer the following questions to the best of your ability.

Are you currently having thoughts of harming yourself or someone else? *YesNo

You Answered "YES"

Thank You for your Input

If you are having thoughts of harming yourself or someone else, it's crucial that you get professional support ASAP.

Please contact the 988 Suicide & Crisis Lifeline.

Simply dialing 988 from any mobile or landline connects the caller directly to a trained crisis counselor
It's free, confidential, and available 24 hours a day, 7 days a week, 365 days a year, and the caller doesn't need to give any personal information to get help.
Texting 988 and chatting online at 988lifeline.org both work as alternatives to calling, useful for someone who can't talk on the phone. No message is needed to start.

You can also go to your nearest emergency room right now for immediate crisis support. We are not equipped for crisis support.

Thank you so much!

Are you currently under the care of a mental health professional or psychiatrist that involves Active and intensive Care - for example: recent hospitalization, intensive outpatient program, or my provider has asked me not to add other support right now *Yes, I AmNo, I Am Not

You Answered "YES" to Ongoing Stable Care

That's Great!

We're glad you have support in place. We may ask for your provider's contact info later just so we can coordinate if needed."

You Answered "YES" to Active and Intensive Care

Thanks for your response

Because you're currently in active or intensive mental health care, we're not able to provide support without written consent from your provider, so we can coordinate care responsibly.

If you'd like us to support you alongside your provider, please have them email us at intake@centryleague.com with your contact information and the current care plan you're participating in.

Thank you so much!

Safety Questions Agreement *I confirm that all the above statements are true, by typing my first and last name below and submitting the form.

First Name *

Last Name

Safety Screening Questions

Prayers for Single Men

Prayers for Married Men

Join Our Email List

Thank you so much for subscribing to our list! To confirm your subscription, please click the link in the confirmation email sent to you. Remember to check your spam folder if you don’t see it. ~To Your Success, The CENTRY™ League

Pin It on Pinterest