What type of therapy are you looking for? *Individual (for myself)Couples (for myself and my partner)Teen (for my child)Which country are you in? *Please select an optionAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweWhat is your gender identity? *MenWomenOtherHow old are you? *Please select an option13-1718-2425-3435-4445-5455-6465 and AboveHow do you identify? *Please select an optionStraightGayLesbianPrefer not to sayQuestioningQueerAsexualI don't knowOtherWould you like to be matched with a therapist who specializes in LGBTQ+ issues? *YesNoWhat is your relationship status? *Please select an optionSingleIn a relationshipMarriedDivorcedWidowedOtherHow important is religion in your life? *Please select an optionVery importantImportantSomewhat importantNot important at allWhich religion do you identify with?IslamChristianityJudaismHinduismBuddhismOtherPrefer not to sayDo you consider yourself to be spiritual? *NoYesHave you ever been in therapy before? *NoYesWhat led you to consider therapy today? *I've been feeling depressedI feel anxious or overwhelmedMy mood is interfering with my job/school performanceI struggle with building or maintaining relationshipsI can't find purpose and meaning in my lifeI am grievingI have experienced traumaI need to talk through a specific challengeI want to gain self confidenceI want to improve myself but I don't know where to startRecommended to me (friend, family, doctor)Just exploringOtherWhat are your expectations from your therapist? A therapist who... *ListensExplores my pastTeaches me new skillsChallenges my beliefsAssigns me homeworkGuides me to set goalsProactively checks in with meOtherI don't knowHow would you rate your current physical health? *GoodFairPoorHow would you rate your current eating habits? *GoodFairPoorAre you currently experiencing overwhelming sadness, grief, or depression? *NoYesUnderstanding Your Recent ExperiencesOver 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 allSeveral daysMore than half the daysNearly every dayMoving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual. *Not at allSeveral daysMore than half the daysNearly every dayFeeling down, depressed or hopeless. *Not at allSeveral daysMore than half the daysNearly every dayTrouble falling asleep, staying asleep, or sleeping too much. *Not at allSeveral daysMore than half the daysNearly every dayFeeling tired or having little energy. *Not at allSeveral daysMore than half the daysNearly every dayPoor appetite or overeating. *Not at allSeveral daysMore than half the daysNearly every dayFeeling bad about yourself - or that you are a failure or have let yourself or your family down. *Not at allSeveral daysMore than half the daysNearly every dayTrouble concentrating on things, such as reading the newspaper or watching television. *Not at allSeveral daysMore than half the daysNearly every dayThoughts that you would be better off dead or of hurting yourself in some way. *Not at allSeveral daysMore than half the daysNearly every dayHow 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 at allSeveral daysMore than half the daysNearly every dayAre you currently employed? *NoYesDo you have any problems or worries about intimacy? *NoYesHow often do you drink alcohol? *Please select an optionNeverInfrequentlyMonthlyWeeklyDailyWhen was the last time you thought about suicide? *Please select an optionNeverOver a year agoOver 3 months agoOver a month agoOver 2 weeks agoIn the last 2 weeksAre you currently experiencing anxiety, panic attacks or have any phobias? *NoYesAre you currently taking any medication? *NoYesAre you currently experiencing any chronic pain? *NoYesHow would you rate your current financial status? *GoodFairPoorHow would you rate your current sleeping habits? *GoodFairPoorWhich of the following resources would be useful for you? *Support groupsTherapy journalWorksheetsGoal/habit trackingEducational webinarsOtherI don't knowHow do you prefer to communicate with your therapist? *Mostly via messagingMostly via phone or video sessionsNot sure yet (decide later)Are there any specific preferences for your therapist? *Male therapistFemale therapistChristian-based therapyOlder therapist (45+)Non-religious therapistBlack therapistWhat is your preferred language? *Please select an optionEnglishPunjabiUrduYou've completed the questionnaire!PhoneNameDate *Time *Hours-120102030405060708091011Minutes-000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859AMPMSend Message
