Self-assessment Form | Pathlight Mood & Anxiety Center

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For Me

For a Friend or Family Member

For a Patient

We're here to help when you need it.

Our licensed therapists welcome your questions. No obligation, no cost. We're here to help.

[The program] gave me the opportunity to explore my mental struggles when I needed it most. I felt safe, heard, and empowered.Taylor, Former Patient

Take the First Step

How can we help you today?

I’d like to speak with a clinician about treatment for a friend or family member

My friend or family member is ready to start treatment

I’m looking for additional resources

We're here to help when you need it.

Our licensed therapists welcome your questions. No obligation, no cost. We're here to help.

1-877-711-1878

[The program] gave me the opportunity to explore my mental struggles when I needed it most. I felt safe, heard, and empowered.Taylor, Former Patient

Find what you need

What information are you looking for today?

Blogs and articles about mood, anxiety and trauma-related disorders

Information about what treatment is like

Resources for family members

Resources for alumni

Resources for medical providers

We're here to help when you need it.

Our licensed therapists welcome your questions. No obligation, no cost. We're here to help.

1-877-711-1878

[The program] gave me the opportunity to explore my mental struggles when I needed it most. I felt safe, heard, and empowered.Taylor, Former Patient

The Basics

Relationship to patient

Your Information

Tell us about yourself:

First Name

Last Name

First Name

Last Name

Phone

Ok to leave a voicemail?

Yes

State

Type of Insurance

Relationship to Policyholder

Condition

We do not accept Medicaid or Medicare plans, with the exception of residents of King County, Washington. Rather than completing this form, please contact your insurance for assistance with seeking care at an in-network facility. If you are a resident of King County, Washington, please call us at 303-825-8595 to discuss the admissions process. Learn about additional treatment options and resources that you may be eligible for here.

If you are not currently insured, please learn about additional treatment options and resources that you may be eligible for here rather than submitting this form, or call us at 1-877-711-1878.

Date of Birth

Enter date in MM/DD/YYYY format.

By entering in your telephone number, you agree to receive transactional SMS notifications and reminders from ERC and Pathlight via short code 73821. Message and data rates may apply. Message frequency may vary. You may receive alerts until you choose to opt out of this service by texting STOP to 73821 or replying STOP to any of our messages. Text HELP to 73821 for assistance.

Patient Information

Patient's First Name

Patient's Last Name

Patient Date of Birth

Enter date in MM/DD/YYYY format.

We're here to help when you need it.

Take the First Step

We're here to help when you need it.

Find what you need

We're here to help when you need it.

We're here to help when you need it.

The Basics

Your Information

Patient Information

Your experience