Internet-Counselor.com Pre Session Form

Internet-Counselor.com

Internet-Counselor.com Pre Session Form

Complete this confidential Pre-Session form. This will be seen only by your therapist. If you prefer you can download a Registration form and fax it to us at 972-529-7002. Click here to download the Registration form.

Take your time while completing this form. Most people report this step helped them prepare for their session and gain valuable insights into the problems/issues that brought them to therapy. Your therapist receives this before your session and reviews it carefully which saves you from wasting valuable time. The more information you provide, the better able your therapist is to help you.

Referred by:
Name:
Email Address:
Home Street Address:
City, State
Zip code
Age:	Gender
Date of Birth: (00/00/0000)
Phone:
Relationship Status:
Current Living Arrangement:
Time lived at current residence:
Have you ever received psychological / counseling / psychiatric services?	If "yes", please describe:
Level of completed education
Current employment situation:
Emergency Contact Name:
Emergency Contact Phone:
Current medications:	if yes, please list name and dosage
List medications that you are allergic to:
Have you ever attempted suicide, or had a plan to harm yourself ? When?
Describe your current usage of alcohol/drugs:
Have you been treated for substance abuse? When?
Do you have (1) current sleep difficulties, or (2) change in appetite?
Briefly describe any medical history you feel is effecting your well being.
Briefly describe any medical symptoms that apply to you: (Ex: nervous, confused, bored, fearful, etc.)
What is it mainly that you want to talk to the counselor about?
Note: This service is not intended for individuals who are actively contemplating suicide or are suffering from a severe mental/emotional disorder. If you are experiencing serious suicidal thoughts, please stop now and phone your local suicide hotline or phone 911 or call 1-800-273-TALK (8255). This service is also not intended for use by minors [under 18 years old].

By submitting this form I acknowledge that I have read and agree with the terms as stated in the HIPPA form.
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