Questionnaire Part One

Questionnaire Part One
(All boxes with asterisks **** must be filled.)

Please read Questionnaire Privacy before filling out this form for important information on privacy when using the Questionnaire.

Personal Information:

First name:  ****         Last name: 

Nickname or preferred name: ****            Sex: Female Male  ****

Street address:

City:    State:   ****  Country:   ****

Zip Code:          Phone number: 

Your email address:           ****

Your email address again:  ****   

Birthdate:           Age:   **** 

Marital status: Married Single Separated Divorced Widowed  ****         Number of marriages: 0 1 2 3 4 4+  ****

Describe your racial/ethnic identity:  ****

1. How many children do you have? Tell me their first names, ages, and anything else about them you think is important or helpful. If none, write "none." (Note: the text boxes will expand to accommodate any length of text):

 ****

2. Who lives in your household?:   ****

3. What is your occupation? Briefly describe your work or typical day if you don't work:

 ****

4. Tell me why you are seeking help at this time. What led to your decision to search the internet for help? Tell me what's going on in as much detail as necessary:

 ****

5. If you are experiencing any of the symptoms below on a regular basis, then use the drop down list to rate each one as Mild (Mild), Moderate (Mod), or Severe (Sev).

sadness/tearfulness No Mild Mod Sev     fatigue No Mild Mod Sev     lethargic No Mild Mod Sev     feelings of guilt No Mild Mod Sev  

feelings of hopelessness No Mild Mod Sev     feelings of worthlessness No Mild Mod Sev     sleeping too much No Mild Mod Sev  

insomnia No Mild Mod Sev     loss of appetite No Mild Mod Sev     eating too much No Mild Mod Sev     irritability No Mild Mod Sev    

anger No Mild Mod Sev     loss of pleasure No Mild Mod Sev     poor concentration No Mild Mod Sev     suicidal thoughts No Mild Mod Sev

homicidal thoughts No Mild Mod Sev     anxiety No Mild Mod Sev     excessive worry No Mild Mod Sev     panic attacks No Mild Mod Sev

afraid to leave home No Mild Mod Sev     can't stop compulsive habits (washing hands, checking, etc.) No Mild Mod Sev

restlessness No Mild Mod Sev     easily distracted No Mild Mod Sev     impulsive No Mild Mod Sev      easily startled No Mild Mod Sev    

nightmares No Mild Mod Sev     flashbacks No Mild Mod Sev     mood swings No Mild Mod Sev     overenergetic No Mild Mod Sev

feel like do not need to sleep No Mild Mod Sev     rapid speech No Mild Mod Sev     racing thoughts No Mild Mod Sev   

overactive in sex or spending No Mild Mod Sev     grandiosity No Mild Mod Sev     bizarre or unusual behaviors No Mild Mod Sev

paranoia No Mild Mod Sev      hearing voices No Mild Mod Sev      seeing things that aren't there No Mild Mod Sev

binge eating No Mild Mod Sev     purging food No Mild Mod Sev     extremely underweight No Mild Mod Sev     obesity No Mild Mod Sev

self-cutting/self-harming behaviors No Mild Mod Sev     excessive use of alcohol or drugs No Mild Mod Sev

6. If you are experiencing "suicidal thoughts," "homicidal thoughts," "self-cutting/self-harming behaviors," or "bizarre or unusual behaviors," please explain in more detail.

7. Tell me more about any other symptoms you checked above:

8. Tell me about any previous psychiatric hospitalizations (when, where, why), any previous or current mental health counseling, any previous or current psychiatric medications you have taken (when, what, and any benefits or side effects), and any previous or current diagnoses you been given. If none, write "none."

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9. **Tell me about any medical problems you have or have had - chronic illnesses, traumatic injuries, head injuries, major surgeries, chronic pain. If none, write "none."

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10. Tell me about your history of using alcohol and drugs, including cigarettes and any abuse of medications. For example, tell me when you started using alcohol, when it became a problem (if it did), and your current use in the past year and past week. The same for any other drugs - marijuana, cocaine, crack, heroin, etc.. If you have no history, then write "none."

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11. Tell me anything else you think would be helpful for me to know:

12. Choose the service you prefer: ****    Chat TherapyEmail Counseling

13. Are you going to complete Questionnaire Part Two ( (highly recommended):  Yes No