Client Screening Questionnaire

Please fill out this form completely so that we can determine whether our services are appropriate for you.
You will receive an email with user names and password directing you to the site where you can contact us by e-mail or live chat, depending on the service you have chosen.

Screen Name (You may choose to keep your real name confidential):

E-Mail for Reply:

Type of Counseling:
  
Tell me about yourself : (100 words or less)
Brief Description of Problem: (200 words or less)
 
Are you currently in therapy for any issue? Yes No If yes, for what?
Have you ever been in therapy for any reason? Yes No If yes, for what?
Are you taking any medication now? Yes No  List all

Have you ever taken any medication? Yes No

Reason?

List all
Are you using any non-prescription drugs? Yes No List all