Mental Health and Sickness Form "*" indicates required fields Name* First Last Phone*Email* What type of health concern are you experiencing (Pick one) Mental Health Physical Health (Stomach Flu, Strep throat, etc.) What are your current symptoms?Have you been around anyone with a sickness or illness in the last 7 days? Yes No Have you visited a doctor yet? Yes No What can we do to help you?Do you have any other questions or concerns?