Client Questionnaire

Important Note:  Please answer the following 3 questions. If you answer YES to any of them, then online counseling is NOT appropriate for you at this time. 

* Indicates a required field. Limited fields below.

(1) Are you currently having any serious thoughts about committing suicide? If so, please stop reading right now.  Call your local suicide hotline by dialing 911, or go directly to your local hospital’s emergency room.  
* If yes, then please click here.

(2) Are you in the midst of a serious emotional crisis right now? If so, I suggest that you contact a mental health professional in your local area.
*

(3) Do you have serious or intense emotional problems? If so, I suggest that you contact a mental health professional in your local area.
*

(4) Are you under 18 years old?  If so, I would need written consent of a parent or guardian in order to work with you.  Please have your parent or guardian contact me directly by clicking here.
*


Instructions: Please fill out this questionnaire and return it to me.  Please read the Client-Counselor Agreement first before you fill out the questionnaire. 

  *Full Name:

Nickname:

*Gender:

  *Age:

*Marital Status:

*Occupation:

*Employment:

Home Address:

*City:

*State:

Zip Code:

Province:

*Country:

*Home Phone 
(for emergencies purposes only):

*Work Phone 
(for emergencies purposes only):

*Email Address:

*Confirm Email Address:



Please Note: Take all the space you need. The boxes below will expand.

1.  What concern has prompted you to contact me at this point in time?
2.  Why are you interested in online counseling rather than traditional face-to-face counseling at this point?
3.  Have you ever been in treatment with a therapist or counselor in the past? If so, when, and for what problem(s)?  What was the result of this? Are you being treated by a therapist, counselor, or psychiatrist now?
4.  What negative feelings or “symptoms” are you having at this time, e.g. feeling anxious, depressed, sad, angry, frustrated, etc.
5.  How severe would you say your symptoms are? (e.g. mild/moderate/severe)
6.  What have you already tried for this problem?
7.  Have you tried anything that DOES help?
8.  Are you currently taking any psychotropic medication? (e.g. anti-depressants or anti-anxiety medication) If so, what type of doctor prescribed it?  
9.  Have you taken any psychotropic medication in the past? 
10.  Please list all medications you are now taking, including the dosage. Please include prescriptions, over-the-counter, herbal, homeopathic medications and nutritional supplements:
11.  How often do you drink alcoholic beverages?  (e.g. never, rarely, occasionally, frequently, or heavily):
12.  How often do you use recreational drugs? (e.g. never, rarely, occasionally, frequently, or heavily) Also, please list the drugs you use:
13.  Whom do you live with currently? 
14.  If you are married or have a "significant other" or long-term partner, what is that person's name?  How long have you been together?  Please describe your relationship.  
15.  Do you have any children?  If so, what are their names and ages?
16.  Do you have any brothers or sisters?  Where are you in the sibling order? (e.g. oldest, middle, youngest) Where do they live and how do you get along with them?
17.   Are your parents alive? Where do they live and how do you get along with them?
18.  Do you have in-laws?  Where do they live and how do you get along with them?
19.  How much education have you completed?
20.  If you are a student now, what school are you in, how are your grades, and how do you like school? If you are in college or graduate school, what is your major? 
21.  Are you happy with your current