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Step
2. Complete this confidential Pre-Session form.
This will be seen only by your therapist. For
problems with the form or if you have questions, use
the Live Support icon above or call Customer Support at
1-866-450-3463.
Return to Therapists
Take your time while completing this form. Most people
report this step helped them prepare for their session and
gain valuable insights into the problems/issues that
brought them to therapy. Your therapist receives this
before your session and reviews it carefully which
saves you from wasting valuable time. The more information
you provide, the better able your therapist is to help
you.
Payment is required before your session. - Use this link
to purchase
your session.
Step 3.
Schedule
Your Appointment
* When
scheduling, enter Your
Therapist's Time Zone - Use this
link if you're not sure how to convert time zones. |
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Referred
by: |
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My
Online Therapist's Name |
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Name: |
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Email
Address: |
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Home Address:
Street:
City, State
Zip code
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Age: |
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Gender
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Date
of Birth: (00/00/0000) |
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Phone: |
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Relationship
Status: |
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Current
Living Arrangement: |
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Time
lived at current residence: |
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Have
you ever received psychological / counseling / psychiatric
services? |
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If "yes", please describe:
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Level
of completed education: |
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Current
employment situation: |
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Current
medications: |
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if
yes, please list name and dosage
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PROBLEM
CHECKLIST (check
any symptoms that apply whether problem heading is correct
or not) |
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Depression |
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chronic
sadness |
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low
frustration tolerance |
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crying
episodes |
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irritability |
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hopelessness |
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sleep
problems |
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difficulty
concentrating |
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memory
problems |
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weight
loss |
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thoughts
of suicide |
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weight
gain |
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withdrawing
from others |
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loss
of appetite |
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difficulty
functioning at work |
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overeating |
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difficulty
functioning socially |
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nausea/vomiting |
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low
energy/fatigue |
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difficulty
making decisions |
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reduced
interest/pleasure |
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recurring
thoughts of death or dying |
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feelings
of worthlessness/guilt |
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Anxiety |
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agitation |
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panic
attacks |
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restlessness |
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fear
of leaving home |
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excessive
worry |
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avoidance
of public places |
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fearfulness |
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avoidance
of social situations |
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trembling/shaking |
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pounding
heart/palpitations/shortness of breath |
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fear
of loss of control |
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chest
pain |
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fear
of dying |
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Stress/Trauma |
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Feeling
detached from others/life |
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Flashbacks/re-living
bad experiences |
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Intrusive
thoughts of bad memories |
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Easily
startled/upset |
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Nightmares |
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Substance
Abuse |
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Excessive
use of alcohol/drugs |
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Fail
at effort to reduce use of alcohol/drugs |
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Use
substances to cope with difficult feelings/life problems |
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Legal
problems related to substance use |
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History
of substance abuse in family |
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Cigarette
use is troublesome/causing health problems |
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Memory
loss following substance use |
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Unconsciousness
due to substance use |
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Health
problems/accident(s) due to substance use |
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Substance
use causing problems problem
with friends/family/work |
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Eating
Problems |
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Excessive
eating |
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Obesity |
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Underweight |
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Self-induced
vomiting |
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Use
of laxatives |
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Obsessing
about food, diet, exercise |
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Eating
problems interfering with health |
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Thinking
Problems |
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Hearing
voices others do not hear |
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Seeing
things others do not see |
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Fearful
others are talking about you |
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Fearful
someone is plotting against you |
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Attention
and Behavior |
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Difficulty
completing tasks/distractible |
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Taking
on more tasks than can be completed |
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Difficulty
focusing |
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Frequent
forgetfulness |
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Tendency
to be impulsive |
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Difficulty
waiting your turn |
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Not
well organized |
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Difficulty
at work/do not stay on the same job |
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Problems
with co-workers |
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Problems
with co-workers |
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Problems
with legal authorities |
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Problems
in school growing up |
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Other
Problem Areas |
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Racing
thoughts |
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Staying
up for days without sleep |
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Excessive
spending |
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Excessive
gambling |
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High
risk sexual behavior |
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Aggressive/abusive
toward others |
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Confused/worried
about sexual behavior |
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Marital
conflict |
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Parent-child
conflict |
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Other
family conflicts |
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If
you are experiencing serious suicidal thoughts ,
please stop now and phone your local suicide
hotline or phone 911.
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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:
1. Describe the problem in a very specific and
understandable way.
2. How
long has the problem been present? (When/How did it
start?)
3. Why did you decide to seek help now, through e-therapy?
4. Who is involved/affected by the problem.
Describe their involvement.
5. 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?
6. What would the first small sign be that tells you the
problem
is beginning to improve or change for
the better?
*Do not use the "enter"
key it will submit your form.
Continue typing and the form will format your response.
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.
(Do not hard return using
the enter key) |
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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.
(Do not hard return using
the enter key))
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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 your local crisis
hotline and/or find a local mental health
professional. This service is also not intended for use by
minors [under 18 years old]. |
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Terms
and Use of Privacy Agreement
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Please
select type of consultation: |
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I
UNDERSTAND AND AGREE TO THE TERMS OF USE AGREEMENT
AND CHOOSE TO ACCESS SERVICES
I DO NOT AGREE TO THE TERMS OF USE AGREEMENT
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