ACCOUNT INFORMATION
Username
(*)
password
(*)
USER INFORMATION
First Name
(*)
Last Name
(*)
Email
(*)
Gender
Male
Female
(*)
Occupation
Marital Status
Single
Married
Windowed
Divorced
Mobile
Telephone
(*)
Address
(*)
City
(*)
State
(*)
Zip Code
(*)
Have you ever received any form of counseling/mental health services?
(*)
Yes
No
Is there a history in your family of mental disorders or substance abuse problems?
(*)
Yes
No
Are you currently having suicidal thoughts?
(*)
Yes
No
Choose topic or symptom for which you are now seeking help?
(*)
Relationships
Depression
Anxiety substance abuse/addiction
Self Esteem
Grieving
Family/parenting
Divorce
Other
Why are you choosing online therapy?
(*)
Privacy
Cost
Easy access
You are too busy to engage in formal therapy
Discomfort with face to face personal disclosure
(*) FIELD REQUIRED
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