Individual Form Step 1 of 9 11% What is your gender identity?(Required) Woman Man Other How old are you?(Required)131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899What is your relationship status? Single In relationship Married Divorced Widowed Other How do you identify?(Required) Straight Gay Lesbian Bi/Pan Prefer not to say Other Do you consider yourself to be religious? Yes No Prefer not to say Do you consider yourself to be spiritual? Yes No Prefer not to say What led you to consider therapy today?(Required) I've been feeling depressed I feel anxious anxious or overwhelmed My mood is interfering with my job/school performance I struggle with building or maintaining relationships I can't find purpose and meaning in my life I am grieving I have experienced trauma I need to talk through a specific challenge I want to gain self confidence I want to improve myself but i don't know where to start recommended to me (friend, family, doctor) Just exploring Have you ever been in therapy before?(Required) Yes No What are your expectations from your therapist? A therapist who ...(Required) Listens Explores my past Teaches me new skills Challenges my beliefs Assigns me homework Guides me to set goals Proactively checks in with me I don't know How would you rate your current physical health? Good Fair Poor Are you currently experiencing overwhelming sadness, grief, or depression? Yes No How would you rate your current eating habits? Good Fair Poor over 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 the days Nearly every day Moving 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 all Several days More than half the days Nearly every day Feeling down, depressed or hopeless. Not at all Several days More than half the days Nearly every day Trouble falling asleep, staying asleep, or sleeping too much. Not at all Several days More than half the days Nearly every day Feeling tired or having little energy. Not at all Several days More than half the days Nearly every day 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 at all Several days More than half the days Nearly every day Please fill out this short questionnaire to provide some background information about you and the issues you'd like to deal with in therapy. It would help us match you with the most suitable therapist for you. Your answers will also give this therapist a good starting point in getting to know you.Are you currently employed? Yes No Do you have any problems or worries about intimacy? Yes No How often do you drink alcohol? Never Infrequently Monthly Weekly Daily When was the last time you thought about suicide? Never Over a years ago Over a month ago Over a week ago Every day How do you prefer to communicate with your therapist? Mostly via messaging Mostly via messaging Not sure yet (decide later) 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 Are there any specific preferences for your therapist? Male therapist Female therapist Christian-based therapy Therapist from the LGBTQ+ community Older therapist (45+) Non-religious therapist Therapist of color Who referred you to Avadaroon?(Required) Celebrity Youtube Tiktok TV Other Which country are you in? What is your preferred language? Please mark all that apply(Required) I'm a student I'm a veteran I'm disabled I'm unemployed I'm employed but my income is low I'm financially impacted by the coronavirus outbreak Are there any issues you'd like to focus on? We want to match you with a therapist who suits your needs.Additional focus areas I prefer Communication Problems Life Purpose Isolation/Loneliness Self-Love Social Anxiety and Phobia Guilt and Shame Post-traumatic Stress Panic Disorder and Panic Attacks Control Issues Forgiveness Caregiver Issues and Stress Pregnancy and Childbirth Divorce and Separation Attachment Issues Abandonment Body Image Mood Disorders Impulsivity Workplace Issues Money and Financial Issues Chronic Pain Illness and Disability Women's Issues Men's Issues Sexuality Midlife Crisis Narcissism I prefer a therapist with experience in... Depression Stress and anxiety Coping with addictions LGBT-related issues Relationship issues Family conflicts Trauma and abuse Coping with grief and loss Intimacy related issues Eating disorders Sleeping disorders Parenting issues Motivation, self esteem, and confidence Anger management Career difficulties Bipolar disorder Coping with life changes Executive and professional coaching Compassion fatigue Concentration, memory and focus (ADHD) Please specify (in a few sentences) why you'd like therapy. This will give your therapist a good understanding of where to start. What brings you here?
