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Counseling Request Form
Online Counseling
11
Questions
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1
Present problem or issue that brings you to counseling:
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2
Are you currently experiencing suicidal thoughts?
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YES
NO
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3
Have you ever.....
had a history of suicidal thoughts/desires
attempted suicide
engaged in self-injury
been hospitalized for mental health/emotional issues
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4
Have you had counseling in the past?
YES
NO
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5
Are you experiencing any of the following?
Sadness
Hopelessness
Lack of Motivation
Low Levels of Energy
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6
Are you experiencing any of the following
Anxiety
Stress
Feeling Overwhelmed
Panic
Poor Sleep
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7
Name
First Name
Last Name
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8
E-mail
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9
Phone Number
Area Code
Phone Number
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10
Date of Birth
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11
Relationship Status
Single
Married
Other
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