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.

THERAPY

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questionnaire 1
questionnaire 2
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TOPICS
depression
panic attacks
anger management
addiction
dual diagnosis
grief & loss
codependency 1
codependency 2
childhood trauma
on being a therapist

RESOURCES
Johari window
my child within
reparent WC
shattered
serenity prayer
control/responsibility
empathy
taming the mind
mindfulness
stress management
spam of the mind
self-care
assertiveness
healthy boundaries
meditation
mistaken beliefs
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? / Testimonial / Contact Me / 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 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:  ****
Street address:
City:    State:   ****  Country:   ****
Zip Code:          Phone number: 
Your email address:           ****
Your email address again:  ****   
Birthdate:           Age:   **** 
Marital status:  ****         Number of marriages:  ****
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     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     overenergetic
feel like 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 answering the following question:
Complete this sentence: Lassie was a ... .   
                                     
You might have to click the submit button twice.
 

Be sure to bookmark this website for easy return.


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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? / Testimonial / Contact Me / Sitemap

Carl Benedict is a member of the International Society for Mental Health Online, which has led the way in establishing online counseling standards.

Copyright 2005-2014 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