Dr. Darlene Treese - E-Consultations

E-Consultations:

Full name:
Email address:

Email Consultation

Telephone Consultation

*Background Information:*
Have you had any prior psychotherapy/counseling? If so, when?
Are you currently on any medications? If so, please list and include dosages, if known.
Do you have a family history of mental illness?
Do you have a history of substance abuse or addictions?
Describe your current usage of alcohol and/or drugs:
Have you ever attempted suicide, or had a plan to harm yourself?
Do you currently have any thoughts or feelings of wanting to physically harm yourself? If so, do you have a specific plan to do so?
Have you ever been diagnosed with an eating disorder? Please describe: anorexia? bulimia? over-eating?
Were you physically abused as a child?
Were you sexually abused as a child, or do you suspect that you might have been?
Do you have any current or past major medical problems? Please describe very briefly.
What would you like to see happen as a result of seeking Online Therapy?

Please check each of the items below that you feel apply to you:

Headaches	Nervous	Sleep problems
Want to hurt self	Can't concentrate	Restless
Drug problems	Nightmares	Financial problems
Sex problems	Handicapped	Alcohol problems
Depressed	Can't make friends	Horrible thoughts
Stomach trouble	Feelings of panic	Unable to relax
Home conditions bad	Can't keep a job	Feeling stressed

Did I overlook any question which should apply to you, which we need to know? Please enter this information below.

Thank you! You will be directed back to this page to pay for the service you selected.

Note: This service is not intended for individuals who are actively contemplating suicide or are suffering from a severe mental/emotional disorder. If this describes you, please contact 911 and/or find a local mental health professional.

I have several different payment options available for your convenience. Options include:

Pay $75 for 1 - 30 Minute Telephone Consult
Pay $150 for 1 - 60 Minute Telephone Consult
Pay $300 for 4 - 30 Minute Email Consults