Confidential Questionnaire - aPrivateTalk

Complete this confidential Pre-Session form. This will be seen only by your therapist. 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. Disregard if already paid.

Referred by:
Name:
Email Address:

Home Address:
City, State
Zip code


,
Age: Gender
Date of Birth: (00/00/0000)
Phone:
Relationship Status:
Current Living Arrangement:
Time lived at current residence:
Have you ever received psychological / counseling / psychiatric services?
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
  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
Anxiety
  agitation panic attacks
  restlessness fear of leaving home
  excessive worry avoidance of public places
  fearfulness avoidance of social situations
  trembling/shaking pounding heart/palpitations/shortness of breath
  fear of loss of control chest pain
  fear of dying
Stress/Trauma
  Feeling detached from others/life Flashbacks/re-living bad experiences
  Intrusive thoughts of bad memories Easily startled/upset
  Nightmares
Substance Abuse
  Excessive use of alcohol/drugs Fail at effort to reduce use of alcohol/drugs
  Use substances to cope with difficult feelings/life problems Legal problems related to substance use
  History of substance abuse in family Cigarette use is troublesome/causing health problems
  Memory loss following substance use Unconsciousness due to substance use
  Health problems/accident(s) due to substance use Substance use causing problems problem
with friends/family/work
Eating Problems
  Excessive eating Obesity
  Underweight Self-induced vomiting
  Use of laxatives Obsessing about food, diet, exercise
  Eating problems interfering with health
Thinking Problems
  Hearing voices others do not hear Seeing things others do not see
  Fearful others are talking about you Fearful someone is plotting against you
Attention and Behavior
  Difficulty completing tasks/distractible Taking on more tasks than can be completed
  Difficulty focusing Frequent forgetfulness
  Tendency to be impulsive Difficulty waiting your turn
  Not well organized Difficulty at work/do not stay on the same job
  Problems with family Problems with co-workers
  Problems with legal authorities Problems in school growing up
Other Problem Areas
  Racing thoughts Staying up for days without sleep
  Excessive spending Excessive gambling
  High risk sexual behavior Aggressive/abusive toward others
  Confused/worried about sexual behavior Marital conflict
  Parent-child conflict Other family conflicts

If you are experiencing serious suicidal thoughts, please stop now and phone your local suicide hotline or phone 911 or call 1-800-273-TALK (8255).

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?

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.

Note: This service is not intended for individuals who are actively contemplating suicide or are suffering from a severe mental/emotional disorder. If you are experiencing serious suicidal thoughts, please stop now and phone your local suicide hotline or phone 911 or call 1-800-273-TALK (8255). This service is also not intended for use by minors [under 18 years old].



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