Telephone Counseling

Counseling Session Form

Fir st Name
Last Name
Mailing Address
City	ST Zip Code

Home Telephone
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Office Telephone
Please enter your work phone number with area code.

Cell or Mobile Telephone
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Preferred Telephone Contact (for me to call you)

Date of Birth mm/dd/yyyy

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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

Select all that apply:
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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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?

Select Preferred Session Times
Number of Telephone Sessions
Select Number of Sessions
Please make a note of your selection. You will need your desired number of sessions in order to complete registration.
Telephone Appointment 1
Select Preferred Month
Select Preferred Day of Week
Select Preferred Time of Day
Telephone Appointment 2
Select Preferred Month
Select Preferred Day
Select Preferred Time
Telephone Appointment 3
Select Preferred Month
Select Preferred Day
Select Preferred Time

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 aldenlmillermslpc@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.

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Online Counseling & Psychotherapies

Online Counseling and Psychotherapies

Telephone Counseling

Counseling Session Form

Select all that apply:

Select Preferred Session Times

Number of Telephone Sessions

Telephone Appointment 1

Telephone Appointment 2

Telephone Appointment 3

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Online Counseling & Psychotherapies

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