Your Age*
What Type of Therapy are you looking for?*
Gender*
How do you identify?*
Relationship Status*
Are you religious?*
Have you ever been to therapy before?*
What led you to consider therapy today?*
What are your expectations from your therapist? A theripist who…*
Rate your current physical health*
Rate your eating habits*
Over the past 2 weeks, how often have you been bothered by any of the following problems: (Copy)
Are you currently experiencing overwhelming sadness, grief, or depression?*
Over the past 2 weeks, how often have you been bothered by any of the following problems: (Copy)
Little Interest or pleasure in doing things.*
Over the past 2 weeks, how often have you been bothered by any of the following problems: (Copy)
Feeling down, depressed or hopeless.*
Over the past 2 weeks, how often have you been bothered by any of the following problems: (Copy)
Trouble falling asleep, staying asleep, or sleeping too much.*
Over the past 2 weeks, how often have you been bothered by any of the following problems: (Copy)
Feeling tired or having little energy*
Over the past 2 weeks, how often have you been bothered by any of the following problems: (Copy)
Poor appetite or overeating*
Over the past 2 weeks, how often have you been bothered by any of the following problems: (Copy)
Feeling like you’re a failure or that you’ve let your family down.*
Over the past 2 weeks, how often have you been bothered by any of the following problems: (Copy)
Trouble concentrating on things*
Thoughts that you would be better off dead or hurting yourself in some way.*
Are you currently employed?*
How often do you consume alcohol?*
When is the last time you considered suicide?*
Are you currently on any medications?*
