Help is Only a Click Away          eTherapistsOnline.com CONFIDENTIAL CLIENT PRE-SESSION FORM
		Step 2. Complete this confidential Pre-Session form. This will be seen only by your therapist.  For problems with the form or if you have questions,  use the Live Support icon above or call Customer Support at 1-866-450-3463. Return to Therapists 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. Payment is required before your session. - Use this link to purchase your session. Disregard if already paid. Step 3. Schedule Your Appointment * When scheduling, enter Your Therapist's Time Zone - Use this link if you're not sure how to convert time zones.
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		My Online Therapist's Name		Select Marlene Shiple Ellen Bobruff-Reese Arlene Unger Kristen Patterson Catherine Cain Cassandra Cheshire Karen Turner Paul Seitz Pamela Wilder Patricia Brawley Carolyn Rounds Deborah Hecker Pamela Cullen Carol Kryder
		Name:
		Email Address:
		Home Address: Street: City, State Zip code
		Age:		Gender Male Female
		Date of Birth: (00/00/0000)
		Phone:
		Relationship Status:		single married committed relationship separated divorced widowed remarried
		Current Living Arrangement:		alone roommate/s spouse other family members
		Time lived at current residence:
		Have you ever received psychological / counseling / psychiatric services?		Select yes no If "yes", please describe:
		Level of completed education:
		Current employment situation:
		Current medications:		Select Yes No if yes, please list name and dosage
		PROBLEM CHECKLIST (check any symptoms that apply whether problem heading is correct or not)
		Depression
		chronic sadness		low frustration tolerance
		crying episodes		irritability
		hopelessness		sleep problems
		difficulty concentrating		memory problems
		weight loss		thoughts of suicide
		weight gain		withdrawing from others
		loss of appetite		difficulty functioning at work
		overeating		difficulty functioning socially
		nausea/vomiting		low energy/fatigue
		difficulty making decisions		reduced interest/pleasure
		recurring thoughts of death or dying		feelings of worthlessness/guilt
		Anxiety
		agitation		panic attacks
		restlessness		fear of leaving home
		excessive worry		avoidance of public places
		fearfulness		avoidance of social situations
		trembling/shaking		pounding heart/palpitations/shortness of breath
		fear of loss of control		chest pain
		fear of dying
		Stress/Trauma
		Feeling detached from others/life		Flashbacks/re-living bad experiences
		Intrusive thoughts of bad memories		Easily startled/upset
		Nightmares
		Substance Abuse
		Excessive use of alcohol/drugs		Fail at effort to reduce use of alcohol/drugs
		Use substances to cope with difficult feelings/life problems		Legal problems related to substance use
		History of substance abuse in family		Cigarette use is troublesome/causing health problems
		Memory loss following substance use		Unconsciousness due to substance use
		Health problems/accident(s) due to substance use		Substance use causing problems problem with friends/family/work
		Eating Problems
		Excessive eating		Obesity
		Underweight		Self-induced vomiting
		Use of laxatives		Obsessing about food, diet, exercise
		Eating problems interfering with health
		Thinking Problems
		Hearing voices others do not hear		Seeing things others do not see
		Fearful others are talking about you		Fearful someone is plotting against you
		Attention and Behavior
		Difficulty completing tasks/distractible		Taking on more tasks than can be completed
		Difficulty focusing		Frequent forgetfulness
		Tendency to be impulsive		Difficulty waiting your turn
		Not well organized		Difficulty at work/do not stay on the same job
		Problems with co-workers		Problems with co-workers
		Problems with legal authorities		Problems in school growing up
		Other Problem Areas
		Racing thoughts		Staying up for days without sleep
		Excessive spending		Excessive gambling
		High risk sexual behavior		Aggressive/abusive toward others
		Confused/worried about sexual behavior		Marital conflict
		Parent-child conflict		Other family conflicts
		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).
		When describing your problem (below) you will help your therapist to provide  the best possible and most relevant response, if you include the following information: 1. Describe the problem in a very specific and understandable way. 2. How long has the problem been present? (When/How did it start?) 3. Why did you decide to seek help now, through e-therapy? 4. Who is involved/affected by the problem.  Describe their involvement. 5. What have you already done to try to solve the problem? What has helped     (even if only a little) and what has failed to help? 6. What would the first small sign be that tells you the problem     is beginning to improve or change for the better? *Do not use the "enter" key it will submit your form.  Continue typing and the form will format your response. Using the suggestions/questions and problem/symptom checklist  above as a guide, please give your therapist a summary of the problem you want help with (Use as much space as you need.  (Do not hard return using the enter key)
		Now that you have described the problem, please ask your therapist the specific question(s) you would like answered, in relation to your  problem, that will provide you with the information you need in order to take the steps that will begin to improve your situation. (Use as much space as you need.  (Do not hard return using the enter key))
		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].
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