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Questionnaire

(Referrals click here)

We will always attempt to provide you with a therapist at a time that is most suitable for you :  
   

Please indicate a range of times you could meet online:

Please indicate preferred day/s:

Please indicate your preferred therapist:
   

For therapist details please see Events Schedule

 
   
Your Details:
 
   
1. Name:
 
2. Age and gender:
 
3. Location:
 
4. Living Situation:
 
5. Occupation:
 
6 .Telephone
   
7. E-Mail Address:
 
8. Have you ever been in therapy or psychiatric care of any kind? Please describe :
 
9. Have you ever taken or are you currently taking any psychotropic medication (antidepressant, mood stabilizer, sleep medicine, anti psychotic,etc.) Please list.
 
10. Have you ever required psychiatric hospitalization? Please describe
 
11. Do you have any medical problems? Please list them, including all medications prescribed for any condition.
 
12. Have you recently had significant change in your sleep pattern or significant weight loss or gain? Yes No
 
13. Have you ever been in a psychotic state - that is, had hallucinations,delusions (like a strong conviction you're being followed or that someone is controlling your thoughts)? Have you ever been diagnosed with schizophrenia or paranoia? Yes No
If answered yes Please describe
 
14. Do you have any thoughts of suicide? Have you ever tried to harm yourself in any way? Yes No

If answered yes Please describe
15. Do you have any thoughts of doing harm to others? Have you ever physically hurt anyone? Yes No
If answered yes Please describe
16. Tell me what brings you to therapy at this time. What kind of issues would you like to talk about? Also, tell me a little about yourself and your
background.
I have read & agree to the General Disclaimer & in the legal section of the web site
I have read & agree to the Privacy Statement in the legal section of the web site