Intake Questionnaire
Fill out the form below and we'll get back to you as soon as possible with a match.
Name
Email
Phone
How old are you?
What kind of support are you looking for?
What is this?
Select an option
Licensed Therapist
Student Therapist
Peer support
What is your gender identity?
Select an option
Man
Woman
Nonbinary
Transfeminine
Transmasculine
Agender
I don't know
Prefer not to say
Other
How do you identify?
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Straight
Gay
Lesbian
Bi or Pan
Prefer not to say
Questioning
Queer
Asexual
I don't know
Other
Would you like to be matched with a therapist who specializes in LGBTQ+ issues?
Select an option
No
Yes
What is your relationship status?
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Single
In a relationship
Married
Divorced
Widowed
Other
How important is religion in your life?
Select an option
Very important
Important
Somewhat important
Not important at all
Which religion do you identify with?
Select an option
Christianity
Islam
Judaism
Hinduism
Buddhism
Other
Prefer not to say
Do you consider yourself to be spiritual?
Select an option
No
Yes
Have you ever been in therapy before?
Select an option
No
Yes
What led you to consider therapy today?
Select an option
Stress or anxiety
Depression or sadness
Relationship issues
Trauma or past experiences
Grief or loss
Life transitions (e.g., job change, relocation)
Self-improvement or personal growth
Emotional regulation or coping skills
Other
Would you prefer a therapist who is gentle or direct?
Select an option
Gentle
Somewhat gentle
No preference
Somewhat direct
Direct
Would you prefer a therapist who is flexible or structured?
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Flexible
Somewhat flexible
No preference
Somewhat structured
Structured
How would you rate your current physical health?
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Good
Fair
Poor
How would you rate your current eating habits?
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Good
Fair
Poor
Are you currently experiencing overwhelming sadness, grief, or depression?
Select an option
No
Yes
Over the past 2 weeks, how often have you been bothered by any of the following problems:
Little interest or pleasure in doing things?
Select an option
Not at all
Several days
More than half the days
Nearly every day
Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual?
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Not at all
Several days
More than half the days
Nearly every day
feeling down, depressed, or hopeless?
Select an option
Not at all
Several days
More than half the days
Nearly every day
Trouble falling asleep, staying asleep, or sleeping too much?
Select an option
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy?
Select an option
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating?
Select an option
Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself - or that you are a failure or have let yourself or your family down?
Select an option
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television?
Select an option
Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way?
Select an option
Not at all
Several days
More than half the days
Nearly every day
How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Select an option
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Financial/Overall Wellbeing:
Are you currently employed?
Select an option
No
Yes
Do you have any problems or worries about intimacy?
Select an option
No
Yes
How often do you drink alcohol?
Select an option
Never
Infrequently
Monthly
Weekly
Daily
When was the last time you thought about suicide?
Select an option
Never
Over a year ago
Over 3 months ago
Over a month ago
Over 2 weeks ago
In the last 2 weeks
Are you currently experiencing anxiety, panic attacks, or have any phobias?
Select an option
No
Yes
Are you currently taking any medication?
Select an option
No
Yes
Are you currently experiencing any chronic pain?
Select an option
No
Yes
How would you rate your current financial status?
Select an option
Good
Fair
Poor
How would you rate your current sleeping habits?
Select an option
Good
Fair
Poor
How do you prefer to communicate with your therapist?
Select an option
Mostly via messaging
Mostly via phone or video sessions
Not sure yet (decide later)
Are there any specific preferences for your therapist?
Select an option
Man
Woman
Older (45+)
Black
LGBTQ
Experienced in anxiety/depression
Specialize in CBT
Specialize in DBT
No specific preference
Any other information you'll like to share?
How did you hear about us?
Select an option
Referral from a friend or family member
Online search (Google, etc.)
Social media
Advertisement (TV, radio, print)
Doctor or healthcare provider
Other
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