Serenity Online Therapy offers SSL encryption protocol to insure privacy in online counseling. Serenity Online Therapy offers secure Video, Phone, and Chat Therapy and Email Counseling with Carl Benedict, a licensed professional counselor.


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questionnaire 1
questionnaire 2

contact me


anxiety/panic attacks
cope with flashbacks
anxiety & depression
anger management
dual diagnosis
grief & loss
grief suggestions
codependency 1
codependency 2
 coda recovery
childhood trauma
on being a therapist

Carl's Videos
Johari window
my child within
shame & guilt
fear of intimacy
reparent WC
serenity prayer
taming the mind
stress management
spam of the mind
healthy conflict
healthy boundaries
mistaken beliefs
IQ vs. EQ
happiness habits
Pollyanna thinking
basic human rights
helpful quotations
helpful books
helpful movies
helpful links

Carl Benedict offers online counseling on his web site Serenity Online Therapy.
HomeMy Credentials / Counseling Philosophy / Online Therapy Risks & Benefits  / Services & Fees / ConfidentialityBegin Therapy / In Crisis Now? / Contact Me / Carl's YouTube Videos / Sitemap

Questionnaire Part One

You must be at least 18 years old to complete the Questionnaires.  
You must not be suicidal or a threat to others - if so, go to In Crisis Now?

Asking you to complete my Questionnaires before we meet sets me apart from other online therapists. I want to study your story and history BEFORE we meet, so we can begin therapy immediately, which will save you money because I won't have to gather this important information during your paid session (as most therapists do). Thus, our first appointment will be therapeutic rather than just an information-gathering session.

One more thing: Please answer all questions. However, you don't have to provide your last name, birthdate, phone number, or complete mailing address in the Questionnaires. I can gather that information later. However, please provide your city, country, and/or zipcode to determine your time zone for scheduling purposes.

NOTE: I currently have a waiting list. You can inquire about my waiting list by clicking HERE or through my Contact Me form.


Option #1 (Recommended): Request that I email you my Word document version of the Questionnaires for you to complete and then return to me by email.  Click  HERE to request the Word version of the Questionnaires or you can request the Word version of the Questionnaires through my Contact Me form.

 Option #2: (I no longer recommend completing and submitting the Questionnaire below because too many potential clients have reported it will not submit when they click on the Submit buttion.) INSTEAD, PLEASE ONLY USE OPTION #1 ABOVE. I am leaving the Questionnaire Part One (below) and Questionnaire Part Two on my site so you can see the questions that will be asked on the Questionnaire I mail to you, which actually includes both Questionnaires. But, please, do not try to complete the online Questionnaire below because it my not submit and you will have wasted your time.

INFORMED CONSENT: Please read the following important pages that describe Online Therapy Risks & Benefits and Confidentiality so you can be an informed consumer of my services. By requesting my Questionnaire or completing the Questionnaire below, you are acknowledging that you have read these two important links.

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

Personal Information:

FIRST NAME:  ****       LAST NAME:  
NICKNAME OR PREFERRED NAME:  ****          SEX:  ****
CITY:   ****      STATE:  ****      COUNTRY:  ****
YOUR EMAIL ADDRESS:              **** 
BIRTHDATE:            AGE:  **** 
MARITAL STATUS:    ****           NUMBER OF MARRIAGES:   ****
1. How many children do you have? Tell me their first names, ages, and anything about them you think is helpful. If none, write "none."
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 now?
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       fatigue        lethargic       feelings of guilt  
feelings of hopelessness      feelings of worthlessness      sleeping too much  
insomnia       loss of appetite      eating too much       irritability    
anger       loss of pleasure      poor concentration      suicidal thoughts
homicidal thoughts      anxiety      excessive worry     panic attacks
afraid to leave home      can't stop compulsive habits (washing hands, checking, etc.)
restlessness      easily distracted      impulsive      easily startled    
nightmares      flashbacks      mood swings     over-energetic
feel like you do not need to sleep     rapid speech     racing thoughts   
overactive in sex or spending     grandiosity     bizarre or unusual behaviors
paranoia      hearing voices      seeing things that aren't there
binge eating     purging food     extremely underweight      obesity
self-cutting/self-harming behaviors      excessive use of alcohol or drugs
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."
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."
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."
11. Tell me anything else you think would be helpful for me to know:
12. Choose the service you prefer: ****   
13. Are you going to complete Questionnaire Part Two ( (highly recommended): 
Prove that you are a person (rather than a spamming BOT) by completing the following simple equation:
                                                                                10 + 11 = .   
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Click here to request online therapy with Carl Benedict, LCPC, founder of Serenity Online Therapy.

for a new beginning...

HomeMy Credentials / Counseling Philosophy / Online Therapy Risks & Benefits  / Services & Fees / ConfidentialityBegin Therapy /  In Crisis Now? / Contact Me / Carl's YouTube Videos / Sitemap

Copyright 2005-2019 Serenity Online Therapy
All Text and many photos by Carl Benedict

"Our very life depends on everything's recurring till we answer from within."  Robert Frost