By joining today, you will be able to schedule Virtual Email appointments with any of our staff professionals or therapists, join our private discussion groups and automatically be enrolled into our monthly tape give-away.
Already registered? click here. |
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| First Name: |
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| Last Name: |
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| Date of Birth |
example format: MM/DD/YY |
| Time Zone: |
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| Email: |
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| Choose a UserID: |
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| Password: |
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| Confirm Password: |
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| Address 1 |
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| Address 2 |
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| City |
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| State |
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| ZIP/County/Province Code |
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| Country |
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| Emergency Contact Name and Phone Number |
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| Please continue with the following questions: |
| Have you had prior counseling? If so, when and with who? |
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| Are you currently on any medications? If so, please list what they are used for |
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| Are you allergic to any medications? If so, which ones? |
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| Do you have a family history of mental illness or substance abuse? |
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| Have you ever attempted suicide, or had a plan to harm yourself ? When? |
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| Do you currently have any thoughts or feelings of wanting to physically harm yourself ? If so, do you have a plan to do so? |
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| Have you ever been diagnosed with an eating disorder? Describe |
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| Did you experience harsh punishment as a child? |
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| Have you been sexually or physically abused, or do you worry that you might have been? |
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| Describe your current usage of alcohol/drugs: |
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| Have you been treated for substance abuse? When? |
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| Briefly describe any medical history you feel is effecting your well being. |
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| Do you have (1) current sleep difficulties, or (2) change in appetite? |
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| Do you prefer a male or female therapist, and what goal do you have, as a result of eTherapy? |
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| Please check the box in front of any word or phrase you feel applies to you: |
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| How Did You Hear About Us? |
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| Topics of Interests: |
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