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1
Username
First Name
Last Name
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What type of therapy are you looking for?
What is your gender?
Age (years)
3
What is your orientation?
Do you consider yourself spiritual or religious?
What is your relationship status?
Have you ever been in therapy or counselling before?
4
How would you rate your current physical health?
How would you rate you sleeping habits?
How woul you rate your eating habits?
How would you rate you current financial status?
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Are you currently experiencing overwhelming sadness, grief, or depression?
Are you currently experiencing chronic pain?
Are you currently experiencing anxiety, panic attacks or have any phobias?
Are you currently employed?
Do you have any problems or worries about intimacy?
Are you currently taking any medication?
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How often have you been bothered by troubleling falling asleep, or sleeping too much.
How you been bothered by feeling tired or having little energy?
How often you been bothered by poor appetite or overeating?
How often you have been bothered by feeling bad about yourself or have let yourself or your family down?
How you been bothered by trouble concentrating on this things, such as reading the newspaper or watching television?
Have you been bothered by hurting yourself or others in someway?
How often have you been bothered by having difficult problems made it for you to do your work, take care of things at home, or get aling with other people?
How often do you drink alcohol?
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Who referred you to Time2Talk?
Which country are you in?
What is your preferred language?
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I would like to have a therapist who has experience in:
Depression
Stress and Anxiety
Addictions
LGBT (issues)
Relationship (issues)
Family
Abuse
Grief and Loss
Intimacy
Eating disorders
Sleeping disorders
Parenting
Self steem, Motivation
Anger
Career
Bipolar disorder
Bullying/Mobbing
Violence
Other
Tell us:
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