Serenity Online Therapy offers SSL encryption protocol to insure privacy in online counseling. Serenity Online Therapy offers secure chat therapy and email counseling with Carl Benedict, a licensed professional counselor.


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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 Questionnaire.  
You must not be suicidal or a threat to others - if so, go to In Crisis Now?

The purpose of this Questionnaire 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 this Questionnaire. Completing it will take time and thought, but your efforts will pay dividends in the therapy process.

If you are not sure whether to begin with Email Counseling or Video, Phone, or Chat Therapy, please review Services & Fees now because you will be asked to make a choice in the Questionnaire

INFORMED CONSENT: Please read the following important pages that describe My Credentials, My Counseling Philosophy, Online Therapy Risks & Benefits, and 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.

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:  ****
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 sentence:
                                                  Lassie is a... .   
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HomeMy Credentials / Counseling Philosophy / Online Therapy Risks & Benefits  / Services & Fees / ConfidentialityBegin Therapy /  In Crisis Now? / Contact Me / Carl's YouTube Videos / Sitemap

Copyright 2005-2015 Serenity Online Therapy
Text and photos by Carl Benedict except where noted

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