Instructions for Filling out this Form

1. Please take a minute and fill out the questions below by clicking on the space and typing your answer
2. Then, press Submit

Your answers to the following questions will be helpful in planning my responses for you. Please answer each item carefully. The information you provide here is absolutely confidential!

Full Name

Age

Please enter your complete e-mail address

Today's Date (MM/DD/YY)

Nickname/Name you want to be called (8 characters maximum)

How did you learn about The Counseling Center?

What search engine did you use?

What keywords did you use?

Does anyone else have access to your e-mail address?

Yes No

For Billing and Emergency Purposes Only:

Mailing Address

City

State

Zip

Home Phone

Work Phone

Since your financial security is a serious matter please send in your credit card number through our e-mail address or call us. Some people prefer, and feel more secure, sending their card number in two different e-mails.

Type of Credit Card

Visa MasterCard

Credit Card Number

Expiration Date (MM/YYYY)

Checking Account Info

Primary goals of Counseling

What are you unhappy about?

How do you feel about that?

What do you think is the problem?

What specific things do you want to see change in your life? Do you have a specific question for a counselor?

Have your ever received psychiatric or psychological help or counseling of any kind before?

Yes No

If "Yes", please explain.

Are you on any antipsychotic, antidepressant, or anti-anxiety medications?

Yes No

If "Yes", please list, with dosages:

Are you taking any other medications?

Yes No

If "Yes", please list, with dosages:

Living Arrangements

Religious Preference

Name of Church (If Applicable)

Relationship Status:

Single
Married
Divorced
Committed Relationship

Alone
With Roommate
With Spouse
With Family

What is your occupation?

Do you enjoy your job?

Yes No

If you have any serious thoughts about committing suicide, online consults are not appropriate for you at this time. Please stop and call your local suicide hotline by dialing 911.

"I consent to the conditions of e-mail counseling (services and billing) as described at counseling-connections web site, and to the confidentiality limitations (see confidentiality section below). I understand that this is not psychotherapy but a service for support and guidance. I am currently not in crisis and will actively pursue a mental health professional in my community if I have thoughts of harming myself (suicidal thoughts) or anyone else (i.e. violence, etc.)."

Yes No

A hard copy of the agreement is needed for our records, please mail or fax a copy of this agreement with your signature.

Confidentiality:

Interactions between client and counselor are confidential. Unless I have permission, I will not discuss anything that transpires between us with anyone. There are three major exceptions to confidentiality this includes but is not limited to: California law requires all mental health professionals to report:

1. Incidences of child or elder abuse.
2. Intent to commit suicide.
3. Threats to do harm to yourself or another person.

While it is my legal responsibility to report any of the above incidents, it is also my personal and ethical responsibility to help you find a therapist in your area should such thoughts occur.

We will put forth all effort to help you in the shortest amount of time.

Congratulations on having the courage to take this important step. Looking forward to meeting you!