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?