Online Therapy Assessment Form

Online Therapy Assessment Form

All information shared is kept confidential and encrypted
This questionnaire asks for personal information that may illicit feelings of discomfort. Reveal details as you feel comfortable and if answering these questions is more difficult than you anticipated, please let me know. It is not uncommon to feel a bit uneasy after revealing such private information to someone. Submitting this form means that you have also read and agree Let's Talk Online Psychology Service's Terms and conditions.
Full Name*
Gender*
Phone Number*

Area CodePhone Number
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail Address*
Have you previously attended Let's Talk Online?*

YesNo
If yes, give a brief description as to why and when.
Appointment Type
Select which appointment type(s) you require*

Phone TherapyVideo chat TherapyEmail TherapyInstant messaging TherapyNot sure yet
What concern has prompted you to contact me at this time?
Please check all phone and online activities you have experience with*

EmailTextingWhatsAppVideo ChatInstant Messaging / ChatPayment for items / services onlineSocial networks like Facebook or Twitter

IN CASE OF EMERGENCY
Who should be contacted in case of emergency?*
Relationship*
Phone Number*

Area CodePhone Number
INTAKE / BACKGROUND INFORMATION
Have you ever been in treatment with a therapist or counsellor in the past?

YesNo
If so, when were you treated and for what problem(s)? What was the result of this treatment?
Are you experiencing any negative feelings or “symptoms” at this time, e.g. feeling anxious, depressed, sad, angry, frustrated, etc?

YesNo
How severe would you say your symptoms are?
Is there anything specific you have tried in the past or present that you feel has particularly helped you with your difficulties?
If so, describe what this is
Are you currently taking any psychotropic medication (e.g., anti-depressants or anti-anxiety medication)?

YesNo
Have you taken any psychotropic medication in the past?

YesNo
Please list all medications you are now taking, including the dosage.
Please include prescriptions, over-the-counter, herbal, homeopathic medications and nutritional supplements.
How often do you use recreational drugs?
How often do you drink alcoholic beverages?
Have you ever been hospitalized for drug or alcohol abuse, a suicide attempt, “nerves” or other mental health concern?
If so, please give dates and circumstances
If you are married or have a "significant other" or long-term partner, how long have you been together? Do you have any children?
Who lives in the household with you?
Are your parents alive? How do/did you get along with them?
Are you currently working? Are you happy with your current job/career?
If not, why?
How is your overall health? Do you have any medical problems now or in the past that would be helpful for me to know about?
It would be helpful to know about your family of origin, what your childhood was like?
What was your family and life were like when you were growing up?
Have you ever felt in the past like harming yourself or somebody else? Do you have those feelings now?
Is there anything else about you that I should know?
such as ethnicity, disabilities/particular needs, gender preference or sexual identity.
Enter the message as it's shown*
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Online Therapy Assessment Form

Appointment Type

IN CASE OF EMERGENCY

INTAKE / BACKGROUND INFORMATION