Complete this confidential Pre-Session form. This will be seen only by your therapist. Take your time while completing this form. Most people report this step helped them prepare for their session and gain valuable insights into the problems/issues that brought them to therapy. Your therapist receives this before your session and reviews it carefully which saves you from wasting valuable time. The more information you provide, the better able your therapist is to help you. Payment is required before your session. - Use this link to purchase your session. Disregard if already paid.

Referred by:
Email Address:

Home Address:
City, State
Zip code

Age: Gender
Date of Birth: (00/00/0000)
Relationship Status:
Current Living Arrangement:
Time lived at current residence:
Have you ever received psychological / counseling / psychiatric services?
If "yes", please describe:
Level of completed education:
Current employment situation:
Current medications: if yes, please list name and dosage
(check any symptoms that apply whether problem heading is correct or not)
chronic sadness low frustration tolerance
crying episodes irritability
hopelessness sleep problems
difficulty concentrating memory problems
weight loss thoughts of suicide
weight gain withdrawing from others
loss of appetite difficulty functioning at work
overeating difficulty functioning socially
nausea/vomiting low energy/fatigue
difficulty making decisions reduced interest/pleasure
recurring thoughts of death or dying feelings of worthlessness/guilt
agitation panic attacks
restlessness fear of leaving home
excessive worry avoidance of public places
fearfulness avoidance of social situations
trembling/shaking pounding heart/palpitations/shortness of breath
fear of loss of control chest pain
fear of dying    
Feeling detached from others/life Flashbacks/re-living bad experiences
Intrusive thoughts of bad memories Easily startled/upset
Substance Abuse
Excessive use of alcohol/drugs Fail at effort to reduce use of alcohol/drugs
Use substances to cope with difficult feelings/life problems Legal problems related to substance use
History of substance abuse in family Cigarette use is troublesome/causing health problems
Memory loss following substance use Unconsciousness due to substance use
Health problems/accident(s) due to substance use Substance use causing problems problem with friends/family/work
Eating Problems
Excessive eating Obesity
Underweight Self-induced vomiting
Use of laxatives Obsessing about food, diet, exercise
Eating problems interfering with health    
Thinking Problems
Hearing voices others do not hear Seeing things others do not see
Fearful others are talking about you Fearful someone is plotting against you
Attention and Behavior
Difficulty completing tasks/distractible Taking on more tasks than can be completed
Difficulty focusing Frequent forgetfulness
Tendency to be impulsive Difficulty waiting your turn
Not well organized Difficulty at work/do not stay on the same job
Problems with family Problems with co-workers
Problems with legal authorities Problems in school growing up
Other Problem Areas
Racing thoughts Staying up for days without sleep
Excessive spending Excessive gambling
High risk sexual behavior Aggressive/abusive toward others
Confused/worried about sexual behavior Marital conflict
Parent-child conflict Other family conflicts
When describing your problem (below) you will help your therapist to provide the best possible and most relevant response, if you include the following information:

  1. Describe the problem in a very specific and understandable way.
  2. How long has the problem been present? (when/how did it start?)
  3. Why did you decide to seek help now, through e-therapy?
  4. Who is involved/affected by the problem. Describe their involvement.
  5. What have you already done to try to solve the problem? What has helped (even if only a little) and what has failed to help?
  6. What would the first small sign be that tells you the problem is beginning to improve or change for the better?

Using the suggestions/questions and problem/symptom checklist above as a guide, please give your therapist a summary of the problem you want help with (Use as much space as you need.

Now that you have described the problem, please ask your therapist the specific question(s) you would like answered, in relation to your problem, that will provide you with the information you need in order to take the steps that will begin to improve your situation. (Use as much space as you need.)
Judith Allen Michael Robinson Darlene Treese Nancy Tice Terry Olsen