Screening Form and Contact - Elite Sport Mental Health

Full Name

Phone Number

By providing your mobile number you consent to be contacted by SMS. Message and data rates may apply. Message frequency may vary. You can stop messaging by texting STOP and get help by texting HELP. Please refer to elitesportmentalhealth.com/privacypolicy.

Are you currently in a crisis that requires urgent or emergency mental health services? (e.g., suicidal thoughts, urges to harm self, thoughts of harming someone else)

Yes - do not proceed. Please call or text 911, or go to the nearest emergency department No

Are you a current resident of California or Nevada, USA?

Yes No - do not proceed (Dr. Roque's medical license only allows her to treat patients who are currently in California or Nevada)

For athletes only: Are you seeking help to ONLY enhance your sports performance, but otherwise have no current issues (such as depression, anxiety, mood instability, addictions, disordered eating etc.) that interfere with your daily life and would like treatment for?

Yes - do not proceed (ESMH is for treating patients with impairments and dysfunction, not those simply looking to optimize sports performance through psychological strategies) No Not Applicable - not an athlete

Are you specifically looking for ONLY psychotherapy ("talk therapy") from this clinic?

Yes - do not proceed (currently, the clinic does not do therapy only) No

What type of psychiatric services are you seeking?

Sports Psychiatry (Elite Sport Mental Health clinic) - athletes, coaches, high performance individuals General Psychiatry Not sure (you can also visit our websites elitesportmentalhealth.com and rhianaroquemd.com for more information)

Briefly state your interest in the clinic and how we may best assist you.

Back to Forms

Full Name

Phone Number

Message

Back to Forms

Ready for the first step? Start our screening process.

Open screening Form

Not ready to go through screening and just want to send a message?
Click below.

Basic Contact Form

Ready for the first step? Start our screening process.

Not ready to go through screening and just want to send a message?Click below.

Not ready to go through screening and just want to send a message?
Click below.