NetCounselors.com Client Questionnaire

NetCounselors.com Questionnaire

Please fill in the following information. All information will be kept confidential, as with any other communication you provide through your NetCounselor.com sessions.

*Full Name (required)**
*Email (required)**
Date of birth:
Home Address Line 1: (street address)
Home Address Line 2: (city, state and zip)
*Home Telephone Number: (required)**
Work Telephone Number: (optional)
Emergency contact name and number:
Insurance companies do not generally cover eTherapy, If you plan to seek reimbursement from your carrier, list Name and SS# of the policy holder. Be aware that eTherapy records will be requested by the insurance company.
How did you find out about NetCounselors.com?
Please check only the type of sessions you have added to your private account.	eMail eTherapy Therapy Chat (s)

Please continue with these important questions:

Have you had prior counseling? If so, when?
Are you currently on any medications? If so, please list what they are used for
Are you allergic to any medications? If so, which ones?
Do you have a family history of mental illness or substance abuse?
Have you ever attempted suicide, or had a plan to harm yourself ? When?
Do you currently have any thoughts or feelings of wanting to physically harm yourself ? If so, do you have a plan to do so?
Have you ever been diagnosed with an eating disorder? Describe
Did you experience harsh punishment as a child?
Have you been sexually abused, or do you worry that you might have been?
Describe your current usage of alcohol/drugs:
Have you been treated for substance abuse? When?
Briefly describe any medical history you feel is effecting your well being.
Do you have (1) current sleep difficulties, or (2) change in appetite?
What goal do you have as a result of eTherapy?

Please check the box in front of any word or phrase you feel applies to you:

Headaches	Naive	Memory problem
Heart palpitations	Nervous	Unattractive
Sleep problems	Fearful	Bored
Want to hurt self	Timid	Restless
Drug use	Can't concentrate	Nightmares
Financial problems	Worthwhile	Empty feelings
Incompetent	Regrets from past	Fatigue
Tend to be Controlling	Misunderstood	Tense feeling
Shy	Sympathetic	Sex problems
Don't take vacations	Fairly intelligent	Worthless
Confused	Fainting spells	Stupid
Considerate	No appetite	Evil
Handicapped	Regular alcohol use	Over ambitious
Not confident	Depressed	Good person
Can't make decisions	Inadequate	Dizziness
Can't make friends	Disturbing thoughts	Attractive
Stomach problems	Guilty	Lonely
Feelings of panic	Hateful	Not loved
Trembling	Feel Inferior	Confident
Unable to relax	Bad home conditions	Can't keep a job

Please select your preference of Therapist:

Judith Allen

Michael Robinson

Darlene Treese

Nancy Tice

Please add any other information about your background that would be helpful to know, so that your therapist can best help you. This is not the space where you write your "eTherapy Session" but just for additional information you feel your therapist should know about you.