Your Email *

Verify your Email *

Your First Name *

Your Last Name *

Nickname or preferred name *

Town/City *

County/State *

Country United Kingdom Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Timor-Leste Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United States of America Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe

Zip / Postal Code *

Phone Number

Mobile Number

House Number

Preferred date and time (Only for online session)

How old are you *

Gender male
female
*

Marital status Married Single Separated Divorced Widowed

Number of marriages 0 1 2 3 4 4+

Describe your racial/ethnic identity

Describe your personal situation

who lives in your household

what is your occupation

Describe your current problem

What are you expecting to gain from counselling?

What have you done about your problem so far?

Are you receiving counseling from anyone else? Yes No

Use the drop down list to rate each one as Mild (Mild), Moderate (Mod), or Severe (Sev).

Sadness / tearfulness No Mild Moderate Severe

fatigue No Mild Moderate Severe

lethargic No Mild Moderate Severe

feeling of guilt No Mild Moderate Severe

feelings of hopelessness No Mild Moderate Severe

feelings of worthlessness No Mild Moderate Severe

sleeping too much No Mild Moderate Severe

insomnia No Mild Moderate Severe

loss of appetite No Mild Moderate Severe

eating too much No Mild Moderate Severe

irritability No Mild Moderate Severe

anger No Mild Moderate Severe

loss of pleasure No Mild Moderate Severe

poor concentration No Mild Moderate Severe

suicidal thoughts No Mild Moderate Severe

murderous thoughts No Mild Moderate Severe

anxiety No Mild Moderate Severe

excessive worry No Mild Moderate Severe

panic attacks No Mild Moderate Severe

afraid to leave home No Mild Moderate Severe

can't stop compulsive habits (washing hands, checking, etc.) No Mild Moderate Severe

restlessness No Mild Moderate Severe

easily distracted No Mild Moderate Severe

impulsive No Mild Moderate Severe

easily startled No Mild Moderate Severe

nightmares No Mild Moderate Severe

flashbacks No Mild Moderate Severe

mood swings No Mild Moderate Severe

overenergetic No Mild Moderate Severe

Lack of sleep No Mild Moderate Severe

rapid speech No Mild Moderate Severe

racing thoughts No Mild Moderate Severe

overactive in sex or pending No Mild Moderate Severe

grandiosity No Mild Moderate Severe

bizarre or unusual behaviours No Mild Moderate Severe

paranoia No Mild Moderate Severe

hearing voices No Mild Moderate Severe

binge eating No Mild Moderate Severe

purging food No Mild Moderate Severe

excessive use of alcohol or drugs No Mild Moderate Severe

self-cutting/self-harming behaviours No Mild Moderate Severe

extremely underweight No Mild Moderate Severe

obesity No Mild Moderate Severe

seeing things that aren't there No Mild Moderate Severe