Online Counseling Questionnaire Form
First Name
E-mail
Gender
Age Range
18-24
25-34
35-44
45-54
55+
What service are you interested in?
Live Video
Live Chat
E-mail Messaging
What day/time would you prefer to have your session?
Problem or issue to address
Symptoms
Anxiety
Anger Issues
Depressed/Sadness/Down
Sleep Difficulties
Attention/Concentration Difficulties
Nervousness
Low self-esteem
Mood Swings
Obsessive Thoughts/Behaviors
High levels of energy
Grief/Loss
Low levels of energy
Loss of interest
Trouble Breathing
Sweating
Change in eating habits
Lack of motivation
Memories/Flashbacks
Relationship difficulties
How long have symptoms been present?
Have you had counseling in the past?
Yes
No
Medical Symptoms/condition
Pregnant
Cancer
Diabetes
Congestive Heart Failure
Asthma
Allergies
Seizures
Digestive Problems
Chronic Pain
Back issues
Headaches
High Blood Pressure
None
Employment History
Employed
Unemployed
Submit
Should be Empty: