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Email Session Form

First Name
Last Name
Mailing Address
City	ST Zip Code
Home Telephone Please enter your home phone number with area code.
Office Telephone Please enter your work phone number with area code.
Cell or Mobile Telephone Please enter your cell/mobile phone number with area code.
Preferred Telephone Contact (for me to call you)
Email Address *Please enter valid email address
Date of Birth mm/dd/yyyy
Age A value is required.
Relationship Status
Living Situation
Level of Education Completed
Current Employment Status
Have you ever received online counseling?	Yes No
Have you ever received face-to-face counseling?	Yes No
--Number of online sessions
--select MO for appt
--select DAY for appt
Select TIME for appt 1
Select TIME for appt 2
Select TIME for appt 3
	Depression
	Crying Spells
	Sadness that will not go away
	Feeling hopeless or helpless
	Thoughts of death or dying
	Irritability
	Sleeping problems
	Memory problems
	Thoughts of harming yourself or someone else
	Lack of joy or pleasure in activities
	--------------------------------------------------
	Isolating from contact with other people
	Difficulties at work or school
	Difficulties in your social relationships
	Feeling worthless
	Weight loss
	Weight gain
	Loss of appetite
	Overating or binge eating
	Nausea or vomiting
	No energy and/or tired all the time
	--------------------------------------------------
	Anxiety attacks
	Panic attacks
	Excessive worry
	Chest pain
	Shortness of breath
	Body shakes or trembling
	Agitation
	Fear of leaving your home
	Fear of losing control
	Fear of dying
	--------------------------------------------------
	Nightmares
	Flashbacks of traumatic memories
	Easily startled or scared
	High levels of stress
	Difficulty with coping
	Hearing sounds other people do not hear
	Seeing people other people do not see
	Fearing that someone is out to get you
	Fearing that others are talking about you
	Obsessing about what others think of you
	--------------------------------------------------
	Drink more thatn 2 alchoholic beverages per day
	Binge Drink
	Experience blackouts or memory loss
	Excessive use of drugs
	Using drugs or alchohol as a way to cope
	Legal problms because of your drug or alcohol use
	Problems with work or school because of your drug or alcohol use
	Problems with friends or family because of your drug or alchohol use
	Family history of drug or alchohol use
	Unable to quit drugs or alchohol on your own
	--------------------------------------------------
	Sexual behavior out of control
	Excessive gambling
	Excessive shopping or spending
	Excessive eating
	Excessive use of laxatives or enemas
	Excessive focus on food, diet or excercise
	Self-induced vomiting
	Extremely underweight or overweight
	Health problems related to your eating behavior
	Cigarette use is troublesome, and you desire to quit
	--------------------------------------------------
	Engaging in high-risk sexual behaviors
	Difficulty in getting and/or maintaining an erection
	Difficulty achieving an orgasm
	Experiencing premature ejaculations
	Testicular or penile pain with sexual activitiy
	Vaginal or breast pain with sexual activity
	Painful orgasms
	Decreased libido or interest in sexual activity
	Recent (past 12 months) HIV-positive diagnosis
	Recent (past 3 months) diagnosis of non-HIV STD/s
	--------------------------------------------------
	Conflict in primary relationship
	Conflict in social relationships
	Parent-child conflict
	Other family conflict
	Aggressiveness toward others
	Thoughts racing through your head
	Going for days without sleep
	Problems with work or school
	Problems with legal authorities
	Problems with finance
	--------------------------------------------------
	Adult survivor of childhood sexual abuse
	Adult survivor of childhood physical abuse
	Adult survivor of childhood emotional abuse
	Adult survivor of childhood psychological abuse
	Concerns about body image or physical appearance
	Experiencing symptoms of grief or loss
	Having issues related to an online relationship
	Having issues related to using the internet
	Engaging in self-defeating behaviors
	Difficulties with self-esteem and self-worth
	--------------------------------------------------
	Confusion around your sexual orientation
	Concerns about coming out
	Self-loathing because of your sexual orientation
	Difficulties in your life because of your sexual orientation
	Questions about same-sex sexuality, sex in general, fetishes
	--------------------------------------------------
	Spiritual and metaphysical concerns
	Existential concerns (loneliness, emptyness, life-purpose, fear of death)
	Need for toxic religion recovery
	Artistic and creative issues or concerns
	Personal growth and life-enrichment concerns

Please briefly describe your current problem or situation.
When did this start? How long have you struggled with this issue?
What have you already done to address the issue on your own?
How will you know when your situation is getting better?
What motivated you to seek therapy at this time?
Please write any specific question/s you might like to address during your session.
Is there anything else I need to know about you or your situation that would better enable me to help you?
Please be aware that if your email account has spam-guard or a junk-mail feature, you might need to disable it to receive my email response, or look in your spam or junk folder for my reply. Emails will come from me as either @onlinecounseling-psychotherapies.com or @safe-mail.net. I assume no responsibility for emails that get re-directed into a spam or junk mailbox.
Checking the 'I agree to the TERMS OF USE' below, and clicking the SUBMIT button will serve as your electronic signature, acknowledging that you have read, understood, and agree to the TERMS OF USE at Online Counseling-Psychotherapies.com, and attest that you are voluntarily choosing to access my services at this time. If you have any questions or concerns about the TERMS OF USE, please email me prior to submitting this form.
Check one of the following:
I agree to the TERMS OF USE as listed at Online Counseling - Psychotherapies.com. I do not agree to the TERMS OF USE as listed at Online Counseling - Psychotherapies.com.
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Online Counseling & Psychotherapy

Online Counseling and Psychotherapies