Online Therapy Questionnaire

If you would like to make an appointment with one of the therapists on our team, please complete the form below. We use this information so that we can best match you with a therapist who best meets your needs.

Please be assured that all information submitted will be kept completely confidential.

Privacy policy.


    *First Name:

    *Last Name:

    *Therapist Name:

    What are your reasons for seeking therapy at this time?

    What are your goals for therapy?
    What would you like to get out of this experience?

    Have you been in therapy before?
    If so, what was helpful about your experience? What was less helpful?

    Are you currently taking medication?
    If so, what medication are you on?

    Have you received a diagnosis from either a psychologist or a psychiatrist?
    If so, what was the diagnosis?

    Are you currently suicidal?
    Have you made past suicide attempts?

    Do you currently have any issues with substance abuse?

    Have there been substance abuse issues in the past?

    Is there anything else you would like to add that might help us to best understand your needs?