Questionnaire Part One
You must be at least 18 years old to complete the
You must not be suicidal or a threat to others - if so, go to
In Crisis Now?
IMPORTANT: Completing Questionnaire
Part One and Part Two is optional, but PLEASE
read the next paragraph
before deciding not to complete them.
Asking you to complete my thorough Questionnaires
is one thing that sets me apart from other online therapists. I
want to be able to study your story and history BEFORE
we meet for the first time, so we can begin therapy
immediately, which will save you money because I won't need to
gather this important information during your paid session (as most
Thus, our first appointment will be therapeutic rather than just an
ONE MORE THING:
You do not have to provide certain
personal identifying information on this form, such as your last name,
birthdate, phone number, and complete mailing address, since you will be
sending very personal information about yourself. The choice is yours.
However, if you choose not to include your last name, birthdate, phone
number, and/or complete mailing address, I will ask you for this
information in a follow up email because my licensing board does not
allow me to work with clients anonymously. I would like your first name
and city of residence so I can determine your time zone for setting up
appointments. Please answer all other questions on the questionnaires.
CHOOSE ONE OF THREE OPTIONS FOR THE
Option #1: Complete the Questionnaires below.
After you submit Questionnaire Part One, you will be
taken to the briefer Questionnaire Part Two to complete. (Each
will be emailed directly to me when you click on the Submit button.)
Option #2: Request that I
email you my Word document version of the Questionnaires for you to complete and return to
me by email. Click
HERE to request the Word version of the Questionnaires or
request the Questionnaires
through my CONTACT ME FORM.
Option #3: Decline
completing the Questionnaires, in which case I will
gather the Questionnaires information during our first session.
HERE or use the CONTACT ME FORM to let me know you will not be completing the
Questionnaires, and then Pay for your
first session. I will then contact you within 24 hours to set up an
appointment. NOTE: For email counseling, you must complete the
Questionnaires since we will not be meeting in a real-time
appointment so I won't have an opportunity to gather the necessary from
you during a live appointment.
The purpose of my Questionnaires
is to gather information about where your life has been, where it is
now, and where you want it to go so we can formulate the best plan to
help you achieve your goals. I can't emphasize too much the importance
of completing the
Questionnaires, which will take time and thought but
pay dividends in the therapy process.
If you are not sure whether to begin with Video
Therapy, Phone Therapy, Chat Therapy, or Email Counseling, please review
Services & Fees because you will be asked to make a choice in
the Questionnaires. However, at ANY time during the
therapy process, you can change your choice because it is completely up
to you how you want to meet - video, phone, chat, or email.
INFORMED CONSENT: Please read the
following important pages that describe
My Counseling Philosophy,
Online Therapy Risks &
Confidentiality. It is important that you read these pages so you
can be an informed consumer of my services. By completing this
questionnaire and clicking on the submit button, you will be
acknowledging that you have read these pages.