Demo Intake — Mental Health | Evolve Health (Preview)

Step 1 of 15 — Eligibility gates

Eligibility gates

Are you having any urgent symptom or crisis listed above right now? *

No Yes

I confirm each of the following (all must apply): *

I am 18 years of age or older. I am physically located in Texas during this evaluation. I understand this is not emergency care or crisis care. I understand a Clinician will review my answers and treatment is not guaranteed. I understand this service starts with a live video visit — completing this form alone will not result in a prescription.

Your date of birth *

Are you currently thinking about harming yourself or someone else, or do you have a plan or intent to do so? *

No Yes

Step 2 of 15 — About you

About you

Legal first and last name *

Street address *

City *

State *

ZIP code *

Mobile phone *

Email *

How may we contact you about this care?

Phone call Text message Secure portal message

May we leave a generic voicemail (no medical details)? *

Yes No

Emergency contact name and phone (someone we may contact if we are concerned for your safety) *

Your physical location during the video visit will be in Texas (street address if different from above) *

Step 3 of 15 — Identity verification

Identity verification

Before a Clinician can meet with you and consider prescribing, we verify identity — this protects you and keeps online care safe. Upload a clear photo of your government-issued ID (driver license, state ID, or passport) and a live selfie. The name and date of birth on the ID are read from the ID and must match this form, and your selfie is matched to the ID portrait. Your ID and selfie are stored only in your secure chart. If your ID cannot be verified, online prescribing is not available and any medication the Clinician does approve is pickup-only at the pharmacy, where photo ID is verified again at the counter.

Photo of the FRONT of your government ID *

Use whichever is easier — Take a photo opens your camera right here, or upload a photo you already have.

Take a photo

Demo only — files are never uploaded.

Upload a photo

Photo of the BACK of your ID — the barcode side *

The barcode on the back must match the front of your ID. This is how we confirm the ID is genuine.

Take a photo

Upload a photo

Selfie *

Look at the camera like a passport photo — no sunglasses or hat.

Take a photo

Upload a photo

Identity confirmation *

The name and date of birth on my ID match the information on this form. Payment card name matches the name on my ID

Your payment card must be in your own name and match your ID, per program policy.

Step 4 of 15 — Video-first notice and your concern

Video-first notice and your concern

VIDEO-FIRST: Mental health care at Evolve Health starts with a live video visit. This form gathers your history and your PHQ-9 and GAD-7 scores so your video visit is focused and productive. At the end of this form you will book that video visit — no prescription is issued from this form alone. After your video visit, the Clinician may consider a non-controlled medicine, recommend in-person care, arrange follow-up, or explain other options. Stable follow-up visits and refills may later step down to briefer check-ins with repeat scores, as the Clinician directs.

What would you like help with? Check all that apply.

Your main goal for this care

When did these symptoms begin, and have they been steady, improving, or worsening? *

How are symptoms affecting work, school, family, and daily activities? *

Step 5 of 15 — Eligibility for this program: mild-to-moderate, stable adults

Eligibility for this program: mild-to-moderate, stable adults

This program serves adults 18 and older in Texas with mild-to-moderate, stable anxiety and/or depression. Answering honestly helps the Clinician choose safe care — a "yes" below means we will route you to the right level of care, which may be in-person, same-day, or specialist care instead of this online video program.

Check YES for any that apply to you — hard exclusions for this online program:

Bipolar disorder, manic episode, or hypomania — current or past diagnosis Psychosis, schizophrenia, schizoaffective disorder, hallucinations, or delusions — current or past Severe depression or severe anxiety symptoms, or symptoms that are rapidly worsening Hospitalization, emergency care, or crisis care for mental health in the past 12 months Suicide attempt in the past 12 months I am seeking a controlled substance (for example a benzodiazepine, sedative, stimulant, or sleep medicine that is controlled) None of the above

Explain any item you checked

Have you ever been told you have bipolar disorder, mania, or psychosis, even if you are not sure the diagnosis was correct? *

No Yes Unsure

In the past 2 weeks, have you had racing thoughts, needing much less sleep than usual, feeling unusually energetic or impulsive, or feeling unusually important or powerful? *

No Yes

In the past 2 weeks, have you heard or seen things others do not, or held beliefs others tell you are not true? *

No Yes

Step 6 of 15 — PHQ-9

PHQ-9

PHQ-9: Over the last 2 weeks, how often have you been bothered by any of the following problems? Answer every item. Your total score is captured for your Clinician to review with you live on video.

1. Little interest or pleasure in doing things *

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

2. Feeling down, depressed, or hopeless *

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

3. Trouble falling or staying asleep, or sleeping too much *

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

4. Feeling tired or having little energy *

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

5. Poor appetite or overeating *

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down *

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

7. Trouble concentrating on things, such as reading the newspaper or watching television *

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual *

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

9. Thoughts that you would be better off dead or of hurting yourself in some way *

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

PHQ-9 total so far: 0 / 27

If you checked any problems above, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? *

Not difficult at all Somewhat difficult Very difficult Extremely difficult

PHQ-9 severity bands: 0–4 minimal / 5–9 mild / 10–14 moderate / 15–19 moderately severe / 20–27 severe. Scores of 15–27 route to Clinician triage instead of standard booking.

Step 7 of 15 — GAD-7

GAD-7

GAD-7: Over the last 2 weeks, how often have you been bothered by the following problems? Answer every item. Your total score is captured for your Clinician to review with you live on video.

1. Feeling nervous, anxious or on edge *

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

2. Not being able to stop or control worrying *

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

3. Worrying too much about different things *

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

4. Trouble relaxing *

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

5. Being so restless that it is hard to sit still *

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

6. Becoming easily annoyed or irritable *

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

7. Feeling afraid as if something awful might happen *

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

GAD-7 total so far: 0 / 21

If you checked any problems above, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? *

Not difficult at all Somewhat difficult Very difficult Extremely difficult

GAD-7 severity bands: 0–4 minimal / 5–9 mild / 10–14 moderate / 15–21 severe. Scores of 15–21 route to Clinician triage instead of standard booking.

Step 8 of 15 — Additional history and screens

Additional history and screens

If yes, describe — include dates

Have you ever taken medicine for anxiety or depression before? *

No Yes

If yes: medicine name(s), dose, how long, whether it helped, any side effects, and why you stopped

Have you had talk therapy or counseling before, or are you in therapy now? *

No Yes, in the past Yes, currently

Therapist or counselor name and contact (optional, with your consent we can coordinate care)

In the past 12 months, how often have you used alcohol, cannabis, or other recreational substances, and in what amounts? *

Do you use tobacco or nicotine? Type and amount per day (write "None" if none). *

Have you ever had a seizure, severe reaction, or serotonin-related problem (agitation, confusion, fever, tremor, muscle stiffness) from a mental health medicine? *

No Yes Unsure

If yes or unsure, describe

Are you pregnant, possibly pregnant, breastfeeding, or planning pregnancy? *

No Yes Unsure Not applicable

Who is your primary care clinician, and when was your last visit?

Recent labs or records we should know about

Step 9 of 15 — What this program can and cannot prescribe

What this program can and cannot prescribe

If medicine is appropriate after your video visit, this program considers only non-controlled medicines — for example, an SSRI or SNRI or another non-controlled option the Clinician selects for you. Controlled substances are never prescribed in this program: no benzodiazepines, no sedative-hypnotics, no stimulants, no opioids, and no other controlled medicines — not on video, not async, and not as a refill. If you are currently taking a controlled substance prescribed elsewhere, tell your Clinician on video; do not stop it suddenly on your own. No medicine is promised, and starting, continuing, or changing any medicine is decided only after your live video visit.

Program understanding *

I understand controlled substances are never prescribed in this program. I understand no prescription is promised and any prescription requires a live video visit first.

Step 10 of 15 — Red-flag routing

Red-flag routing

For your safety, this form stops and routes you to faster care if any red flag below is present. Stopping this form is routing, not rejection — you will be directed to the level of care that can help you soonest. • Suicidal thoughts, plan or intent, or inability to stay safe: call or text 988 / call 911 / emergency department now. • Psychosis or mania symptoms or history: call (940) 257-2002 for in-person or specialist routing; 988/911 if unsafe. • Severe or rapidly worsening symptoms, PHQ-9 15–27, or GAD-7 15–21: Clinician triage — same-day live pathway. • Chest pain, trouble breathing, stroke symptoms, severe bleeding, or confusion: 911 / emergency department now. • Request for a controlled substance: in-person discussion at (940) 257-2002. • Under 18 or not in Texas: call (940) 257-2002 for in-person help.

Step 11 of 15 — Safety plan

Safety plan

A brief safety plan helps you and your Clinician know the next step if symptoms intensify between now and your video visit. Complete every field. This plan does not replace crisis help — if you may act on urges to harm yourself, call or text 988 or call 911 right away.

Warning signs that tell me I am having a harder time (thoughts, feelings, or situations) *

Things I can do on my own to feel steadier and safer *

People and places that help me feel supported (names) *

People I can ask for help directly, with phone numbers *

Professional contacts: my Clinician / clinic phone (940) 257-2002, therapist if any, and 988 *

What I will do to keep my environment safe (for example, asking a trusted person to hold medicines or other items of concern) *

If my symptoms get worse before my video visit, my next step is:

Call Evolve Health at (940) 257-2002 Call or text 988 Call 911 or go to the emergency department Contact my emergency contact in Section C

Step 12 of 15 — Current medications and allergies

Current medications and allergies

List every prescription medicine, over-the-counter medicine, vitamin, supplement, and recreational substance you currently use. Include dose and how often you take it. Include any mental health medicine, sleep aid, or pain medicine, and say who prescribed it. *

Medication allergies or serious reactions (write "None" if none) *

Have you had an allergic or severe reaction to any SSRI, SNRI, or other mental health medicine? *

No Yes

If yes, medicine name and what happened

Are you currently taking any controlled substance prescribed by another clinician? If yes, list it — for awareness only; this program does not refill controlled substances.

Step 13 of 15 — How you will receive medication

How you will receive medication

This section records your preference only — no medication is prescribed from this form, and any prescription is decided at your video visit. If the Clinician prescribes after that visit, your prescription will be sent to your own pharmacy for pickup. Pickup is recommended for a first prescription: the pharmacy confirms your identity at the counter, which keeps the first fill safest. Insurance can pay for medication only at your own pharmacy. If your ID could not be verified, pickup is the only option.

Pharmacy pickup: *

Pharmacy pickup — prescription sent to the pharmacy I name belowMail delivery — Evolve mail plan: one flat total (visit + medication + shipping); mailed in plain packaging, adult signature required.

Mail delivery is available for most medications — not all. Some medications need refrigeration or special handling, and some addresses can't be reached by mail. If mail isn't possible for your medication or your address, we'll tell you before you pay, and your prescription will go to your pharmacy for pickup instead — no extra visit charge.

If pickup (or if mail isn't possible): pharmacy name and city *

Step 14 of 15 — Booking the video visit

Booking the video visit

Final step: book your live video visit. Your Clinician will review your PHQ-9 and GAD-7 scores with you live, talk through your history and safety plan, and decide together with you whether a non-controlled medicine or another plan is appropriate. Please be in a private place in Texas for the visit, with your photo ID available. If your answers flagged a safety concern, do not wait for a routine booking slot — follow the 988 / 911 guidance shown and expect a same-day live contact instead.

Preferred video visit days and times *

Video visit attestation *

I will be physically in Texas, in a private location, with my photo ID available at my video visit.

Step 15 of 15 — What happens next + payment + consent

What happens next + payment + consent

After review, a Clinician may: ask follow-up questions or verify your identity and location; meet with you on video as booked; request records or lab tests; recommend in-person evaluation; coordinate, with your consent, with your primary care clinician or therapist; or recommend urgent, emergency, or specialist care. No medicine is promised, and no prescription is issued before your live video visit. Payment: your exact visit price is shown before checkout. Your card is authorized when you submit this form and The review fee is captured once the Clinician completes the review, whether or not you are approved for the video-led program. If the Clinician approves treatment after your video visit, any medication cost depends on the pharmacy route you chose in Section N — insurance can pay for medication only at your own pharmacy.

Full legal name (acts as your electronic signature for telehealth consent and identity/age attestation) *

Emergency — please read first

Eligibility gates

About you

Identity verification

Video-first notice and your concern

Eligibility for this program: mild-to-moderate, stable adults

PHQ-9

GAD-7

Additional history and screens

What this program can and cannot prescribe

Red-flag routing

Safety plan

Current medications and allergies

How you will receive medication

Booking the video visit

What happens next + payment + consent

Please pause — next step for your safety

Demo complete