Dr. Darlene Treese

Client Questionnaire:

Please complete this confidential client questionnaire. This form will be seen only by me. Take your time while completing the form. I receive this before your session and review it carefully which saves you from wasting valuable time. Remember you payment is required before your session. You may use this link to purchase your session. You can disregard the link if you already paid.

Referred By:
Name:
Email Address:
Home Street Address:
City:
State:
Zip:
Age:	Gender
Date of Birth: (00/00/0000)
Phone:
Relationship Status:
Current Living Arrangement:
Time at Current Residence:
Previous Counseling?	If "yes", please describe:
Level of completed education:
Current employment situation:
Current medications:	if yes, please list name and dosage

PROBLEM CHECKLIST
(check any symptoms that apply whether problem heading is correct or not)

Depression and Anxiety
	chronic sadness	low frustration tolerance
	crying episodes	irritability
	hopelessness	sleep problems
	difficulty concentrating	memory problems
	weight loss	thoughts of suicide
	weight gain	withdrawing from others
	loss of appetite	difficulty functioning at work
	overeating	difficulty functioning socially
	nausea/vomiting	low energy/fatigue
	difficulty making decisions	reduced interest/pleasure
	recurring thoughts of death or dying	feelings of worthlessness/guilt
	agitation	panic attacks
	restlessness	fear of leaving home
	excessive worry	avoidance of public places
	fearfulness	avoidance of social situations
	trembling/shaking	fear of dying
	fear of loss of control	chest pain
Stress/Trauma
	Feeling detached from others/life	Flashbacks/re-living bad experiences
	Intrusive thoughts of bad memories	Easily startled/upset
	Nightmares
Substance Abuse
	Alcohol/Drugs	Smoking
	Family history substance abuse	Cigarette induced health problems
Eating Problems
	Excessive eating	Obesity
	Underweight or Overweight	Self-induced vomiting
	Use of laxatives	Obsessing about food, diet, exercise

When describing your problem (below) you will help your therapist to provide the best possible and most relevant response, if you include the following information:

Describe the problem in a very specific and understandable way.
How long has the problem been present? (when/how did it start?)
Why did you decide to seek help now, through e-therapy?
Who is involved/affected by the problem. Describe their involvement.
What have you already done to try to solve the problem? What has helped (even if only a little) and what has failed to help?
What would the first small sign be that tells you the problem is beginning to improve or change for the better?

Using the suggestions/questions and problem/symptom checklist above as a guide, please give your therapist a summary of the problem you want help with (Use as much space as you need.

Now that you have described the problem, please ask your therapist the specific question(s) you would like answered, in relation to your problem, that will provide you with the information you need in order to take the steps that will begin to improve your situation. (Use as much space as you need.)

Select Type of Consultation: Email Telephone