Therapeutic Questionnaire

In order to begin the process of online therapy, please let me know a little bit about your history by filling out the form below. All information will be kept confidential in accordance with the terms described in the Online Agreement.

Note: fields with an asterisk "*" next to them are required.

Name: *
Email Address: *
Gender:
Age:
Marital Status :
Education Background :
Employment :
Please Describe the Problem:  
Please discuss what steps you have taken to deal with this problem:
Is there a reason why you are seeking services at this particular time?

It can be assumed that this problem has existed for at least
a short period of time and it might be helpful to know
why you are seeking therapy now.
What are your feelings around this problem:
(sad mad fear guilt shame)
To what extent do you feel depressed as a result of this problem?
(Normal, mild, moderate, severely, extremely)
To what extent do you feel anxiety around this problem?
(Normal, mild, moderate, severely, extremely)
For the depressed and anxiety questions, explain the frequency of episodes,
when do they occur, duration, circumstances associated with episodes and
thoughts associated with episodes.
Are you having troublesome and recurring thoughts that concern you? If yes, explain.
Are you dealing with obsessive thoughts or compulsive behaviors? If yes, explain
Are you having problematic behaviors not listed above that concern you? If yes, explain.
Have you experienced recent weight loss or gain?  Yes No
What is your alcohol consumption like?
How many times per week?
How many times per day?
What are the sizes of the glasses/bottles?
Do you use and form of drugs?   Yes No
Have you recently had insomnia or episodes of oversleeping?  Yes No
If yes, which one?  Insomnia Oversleeping Both
Have you been treated by a mental health professional before?    Yes No
If so, what was it regarding?
What was the outcome?
Enter any other comments you feel are pertinent to this therapy session.

San Diego Therapy

Lily Kotila
Email: Email Lily
Phone 619 218-5363
Address: 1419 University Ave.
                Suite C

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