Anxiety?

Stress?

   Panic Attacks?   

Step 2. Complete this confidential Pre-Session form. This will be seen only by your therapist.  For problems with the form or if you have questions,  use the Live Support icon above or call Customer Support at 1-866-450-3463. Return to Therapists 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. Step 3. Schedule Your Appointment * When scheduling, enter Your Therapist's Time Zone - Use this link if you're not sure how to convert time zones.   Referred by: Select One Search Engine Find-a-Therapist.com AnxietyPanic.com Find-a-Psychologist.com myGoals.com Website not listed Word of Mouth Other   My Online Therapist's Name Select Marlene Shiple Arlene Unger Catherine Cain Cassandra Cheshire, Ph.D. Juliann Mitchell, Ph.D. Angela Winslow   Name:   Email Address:   Home Address: Street: City, State Zip code   Age: Gender Male Female   Date of Birth: (00/00/0000)   Phone:   Relationship Status: single married committed relationship separated divorced widowed remarried   Current Living Arrangement: alone roommate/s spouse other family members   Time lived at current residence:   Have you ever received psychological / counseling / psychiatric services? Select yes no If "yes", please describe:   Level of completed education:   Current employment situation:   Current medications: Select Yes No if yes, please list name and dosage   PROBLEM CHECKLIST (check any symptoms that apply whether problem heading is correct or not)   Depression   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   Anxiety   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   Stress/Trauma   Feeling detached from others/life Flashbacks/re-living bad experiences   Intrusive thoughts of bad memories Easily startled/upset   Nightmares   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 co-workers 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     If you are experiencing serious suicidal thoughts , please stop now and phone your local suicide hotline or phone 911 or call 1-800-273-TALK (8255).   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? *Do not use the "enter" key it will submit your form.  Continue typing and the form will format your response. 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.  (Do not hard return using the enter key)       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.  (Do not hard return using the enter key))     Note: This service is not intended for individuals who are actively contemplating suicide or are suffering from a severe mental/emotional disorder.  If you are experiencing serious suicidal thoughts, please stop now and phone your local suicide hotline or phone 911 or call 1-800-273-8255 (TALK). This service is also not intended for use by minors [under 18 years old].   Terms and Use of Privacy Agreement (Use this link if your browser returns an error message)   Please select type of consultation:   · email consultation [$39.95] - email consultations [$68]/2 email consults - email consults [$100]/3 email consults · email consultation [$125/4 e-mail consults] · online chat session - [$55.00/30 minutes] · online chat session -  [$85.00/60 minutes] · telephone session - [$60.00/30minutes] · telephone session - [$90.00/60 minutes]     I UNDERSTAND AND AGREE TO THE TERMS OF USE AGREEMENT AND CHOOSE TO ACCESS SERVICES

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