What is your gender identity? *

Woman

Man

Prefer not to say

How old are you?

What is your relationship status?

Have you ever been in therapy before?

No

Yes

How would you rate your current physical health?

Good

Fair

Poor

How would you rate your current eating habits?

Good

Fair

Poor

Are you currently experiencing overwhelming sadness, grief, or depression?

Yes

No

Are you currently experiencing overwhelming sadness, grief, or depression?

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. *

Not at all

Several days

More than half days

Nearly every day

Over the past 2 weeks, how often have you been bothered by any of the following problems: Feeling down, depressed or hopeless.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by any of the following problems: Trouble falling asleep, staying asleep, or sleeping too much.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you Feeling tired or having little energy.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by Poor appetite or overeating. *

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. *

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. *

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.

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?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Are you currently employed?

Yes

No

Do you have any problems or worries about intimacy?

Yes

No

Are you currently experiencing anxiety, panic attacks or have any phobias?

Yes

No

Are you currently taking any medication?

Yes

No

Are you currently experiencing any chronic pain?

Yes

No

How would you rate your current financial status?

Good

Fair

Poor

How would you rate your current sleeping habits?

Good

Fair

Poor

How do you prefer to communicate with your therapist?

Mostly via messaging

Mostly via phone or video sessions

Not sure yet (decide later)

Which state are you in? *

Full Name

Phone *

Email *

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