Final Version Digital Experience

1

Are you over 18? Freespira is available to adults and teens age 13 and over

YESNO

2

Are you over 13? Freespira is available to adults and teens age 13 and over

YESNO

3

You are ineligible for Freespira treatment. Freespira is available to adults and teens age 13 and over. Please click Submit to exit the survey.

4

What would you like Freespira to help you with?* This field is required.

Panic attacks

PTSD symptoms

Panic and PTSD symptoms

Something else

I'm not sure

5

Please describe what you would like Freespira to help you with:

6

If you have been diagnosed with PTSD, when were you diagnosed?

Less than 1 year ago

1-5 years ago

5-10 years ago

More than 10 years ago

I haven't been formally diagnosed

7

The next set of questions ask about your symptoms. This will help us to track your improvement with Freespira. We know that questions about your symptoms can be triggering. If you'd rather answer later, we can follow up with you.

Continue to questions

I'd prefer to do this later

8

Do you experience panic attacks?

Yes

No

10

This question talks about 2 different types of panic attacks. Full panic attacks have at least 4 symptoms. Limited symptom attacks have 3 symptoms or fewer. How many of each type did you have in the past month?

No full panic attacks or limited symptom attacks

No full panic attacks. I had some limited symptom attacks, but no more than 1 per day

1 or 2 full panic attacks and/or multiple limited symptom attacks per day

More than 2 full attacks but not more than 1 per day on average

Full panic attacks more than once a day, more days than not

11

In the past month, how distressing were the attacks you had on average?

Not at all distressing, or I didn't have any panic attacks or limited symptom attacks

Mildly distressing (not too intense)

Moderately distressing (intense, but still manageable)

Severely distressing (very intense)

Extremely distressing (extreme distress during all attacks)

12

In the past month, how often did you feel anxious or worried about your next panic attack?

Not at all

Occasionally or only mildly

Frequently or moderately

Very often or to a very disturbing degree

Nearly constantly and to a disabling extent

13

Some people avoid places or situations where they fear having a panic attack. In the past month, how often did you feel afraid or avoid things because of panic attacks?

No fear or avoidance

Occasional fear or avoidance. But I managed to get through the situation and didn't have to make too many adjustments.

Noticeable fear or avoidance. I could get through some situations with a companion, but I did have to adjust my lifestyle. Overall, I was able to do what I needed to do.

Avoiding certain situations meant I had to make major changes in my lifestyle. It was hard to manage my usual activities.

My fear or avoidance was so strong that I simply couldn't do important things.

14

Some people fear doing certain things because the physical feelings remind them of a panic attack. Or they may fear causing an attack. It can be exercise, sex, or bathing. Or it can be drinking coffee or watching a scary movie. In the past month, how often did you feel afraid or avoid activities like this?

I didn't fear or avoid any situations

I felt afraid or avoided things a bit. But usually I could confront it and it wasn't too bad.

I avoided things enough that it meant shifting my lifestyle a bit. But I was able to do what I needed to do.

Avoiding things meant major shifts in my lifestyle. It was hard to do what I needed to do.

My fear or avoidance was so strong that I simply couldn't do important things.

15

Some people fear doing certain things because of the physical sensations they cause. It may remind them of a panic attack. Or they may fear bringing on an attack. It can be exercise, bathing, drinking coffee, or watching a scary movie. In the past month, how often did you feel afraid or avoid activities like this?

I didn't fear or avoid any situations.

I felt afraid or avoided things a bit. But usually I could confront it and it wasn't too bad.

I avoided things enough that it meant shifting my lifestyle a bit. But I was able to do what I needed to do.

Avoiding things meant major shifts in my lifestyle. It was hard to do what I needed to do.

My fear or avoidance was so strong that I simply couldn't do important things.

16

Panic attacks and limited symptom attacks can make it hard to live your life. So can fear and avoidance caused by panic attacks. Think about the past month. How much did these things get in the way of your ability to work or handle responsibilities at home?

They didn't interfere at all.

They interfered a little, but I could do nearly everything I could if I didn't have these problems.

They interfered significantly, but I still could manage to do the things I needed to do.

They interfered a lot. There were many important things I couldn't do because of these problems.

These problems made me essentially unable to manage any work or home responsibilities.

17

Panic attacks, limited symptom attacks, fear, and avoidance can get in the way of your social life. How much was this true for you over the past month?

It didn't get in the way at all.

It held me back a little, but I could do nearly everything I could if I didn't have these problems.

It was a barrier, but I could manage to do most things if I made the effort.

It really held me back from social activities. There were many things I couldn't do.

There was hardly anything social I could do.

19

Could you be pregnant right now?

YESNO

20

We can't offer treatment right now if you're pregnant. If you share your name, e-mail and due date, we can follow up in the future to see if you're still interested in Freespira.

Name

Please enter your email

Due date

21

Have you ever been diagnosed with bipolar disorder, psychosis, or delusional disorder?

Yes

No

I'm not sure

22

Have you ever thought about suicide or tried to end your life?

YESNO

23

Are you having thoughts of killing yourself right now?

YESNO

24

Your safety is our top priority. We recommend you pause this survey and ask you to call or text 988, the Suicide and Crisis Lifeline. The Lifelife offers free, private support 24/7. For other types of emergencies, call 911.

25

If you’re ever struggling or need crisis support, you can call or text 988 for the National Crisis and Support Lifeline. The Lifeline is available 24/7.

26

Are you eligible for benefits through the Veterans Health Administration?This will help us verify your coverage and out-of-pocket costs for Freespira.

YESNO

27

Who is your health insurance provider?* This field is required.This will help us verify your coverage and out-of-pocket costs for Freespira.

28

Please provide the name of your health insurance provider.This will help us verify your coverage and out-of-pocket costs for Freespira

29

What is your health insurance member ID number? You can usually find it on your member ID card.Nothing will be billed to your insurance. You won't be charged unless you consent to treatment with Freespira.

30

What is your health insurance Group ID number? You can usually find it on your member ID card.Nothing will be billed to your insurance. You won't be charged unless you consent to treatment with Freespira.

31

What is your name?* This field is required.

First Name

Preferred Name

Last Name

32

How did you hear about Freespira?

33

What state do you live in?

34

What's your e-mail address?* This field is required.

example@example.com

35

What's your phone number?* This field is required.

Please enter a valid phone number.

36

Disclaimer* This field is required.

37

What is your birth date?

Date

38

Thank you for completing this survey! Our team will follow up with you regarding next steps. How would you prefer us to follow up?

Phone

Text

Email

39

The following questions ask about your PTSD symptoms. This will help us to track your improvement with Freespira. We know that questions about your trauma symptoms can be triggering. If you'd rather answer later, we can follow up with you.

Continue to the questions

I'd rather do this later

40

Repeated, disturbing, and unwanted memories of the stressful experienceHow much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

41

Repeated, disturbing dreams about the stressful experienceHow much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

42

Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

43

Feeling very upset when something reminded you of the stressful experienceHow much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

44

Having strong physical reactions when something reminded you of the stressful experience (for example heart pounding, trouble breathing, or sweating)How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

45

Avoiding memories, thoughts, or feelings related to the stressful experienceHow much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

46

Avoiding reminders of the stressful experience (for example people, places, conversations, activities, objects, or situations)How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

47

Trouble remembering important parts of the stressful experienceHow much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

48

Having strong negative beliefs about yourself, other people, or the world. (This could be thoughts like: I am bad, there is something seriously wrong with me, no one can be trusted, or the world is completely dangerous.)How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

49

Blaming yourself or someone else for the stressful experience or what happened after itHow much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

50

Having strong negative feelings such as fear, horror, anger, guilt, or shameHow much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

51

Loss of interest in activities that you used to enjoyHow much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

52

Feeling distant or cut off from other peopleHow much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

53

Trouble experiencing positive feelings (for example, being unable to feel happy or have loving feelings for people close to you)How much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

54

Irritable behavior, angry outbursts, or acting aggressivelyHow much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

55

Taking too many risks or doing things that could cause you harmHow much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

56

Being super alert, watchful, or on guardHow much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

57

Feeling jumpy or easily startledHow much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

58

Having difficulty concentratingHow much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

59

Trouble falling or staying asleepHow much has this bothered you in the past month?

Not at all

A little bit

Moderately

Quite a bit

Extremely

61

Disease State

PTSD

Panic

Panic & PTSD

Other

62

Is patient over 18

TRUEFALSE

63

record type ID

64

Most Recent Lead Source

65

PDSS Name

66

PCL5 Name

68

Other Pronoun Notes API

70

Is patient Veteran

TRUEFALSE

72

symptom count

73

PDSS Q1

74

PDSS Q2

75

PDSS Q3

76

PDSS Q4

77

PDSS Q5

78

PDSS Q6

79

PDSS Q7

80

Adolecsent

TRUEFALSE

81

PCL5 Q1

82

PCL5 Q2

83

PCL5 Q3

84

PCL5 Q4

85

PCL5 Q5

86

PCL5 Q6

87

PCL5 Q7

88

PCL5 Q8

89

PCL5 Q9

90

PCL5 Q10

91

PCL5 Q11

92

PCL5 Q12

93

PCL5 Q13

94

PCL5 Q14

95

PCL5 Q15

96

PCL5 Q16

97

PCL5 Q17

98

PCL5 Q18

99

PCL5 Q19

100

PCL5 Q20

101

PDSS Total Score

102

PCL5 Total Score

103

Insurance Name