Consult/First e-therapy

E-Consultation/First On-going Session

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Please take the time to complete the following Questionnaire (24 questions), which will provide needed information for a more in-depth review of your problem or situation. Answer each question to the best of your ability. If at some point we think it is important that we know more about you, we may ask you for more identifying information. If we think you require greater or more extensive help, based on your answers, we will refer you to other sources, and possibly recommend you see a therapist/ mental health practitioner locally. You are under no obligation to provide us with information, but insufficient information may limit our ability to be of assistance. The information you supply will be kept confidential, but there can be no guarantee by PsychOptions of absolute security via e-mail or internet transfer of information. Again no diagnoses or treatments can or will be provided over the internet or on-line. If you want to continue with your one-time e-consult with PsychOptions or to begin your first on-going session, please answer the following questions and we will make every attempt to respond respond within 72 hours, except fridays and saturdays (to allow for a full review). Be sure to include the e-mail address to which you want to receive a response.

1. Your e-mail address:

2. Between 1 and 10, how ready are you to change? (Type in a number: with 1 = not ready; 5 = somewhat ready and 10 = totally ready and committed)

3. In the following box, please type in your age, sex, occupation, marital status, level of education (last year completed), employed or not? If you want to provide any other information such as your name, address, and phone number, please do so here.

Please provide your age, sex, marital status, level of education, employment status, occupation and anything else you may want to include:

4. Tell me who lives with you and how they are related to you? If you have children, what are their ages and gender? Do they live with you? Do you have any pets? If so, tell me about them.

Who lives with you and what is the relationship? If any children, what are their ages? Do they live with you? Any pets? Please describe.

5. Describe in the following block any symptoms you are experiencing related to sleep ( unable to fall asleep, wake up in the night, or wake up in the early AM and can’t go back to sleep); eating (lost your appetite and/or weight loss; overeat and/or weight gain; sexual desire; thoughts ( slowed/ fast/racing/ concentration/ decision making); mood ( happy/ sad). For how long have you had these symptoms and how severe are they?

Please describe any symptoms related to sleeping problems, eating, sexual desire, thoughts and mood. When did these start and how svere are they?

6. Do you have any other symptoms (nervousness/fear/phobias/hand washing etc.) or physical symptoms: heart pounding/sweating/feeling faint/stomach problems, etc. Please describe any symptoms, including physical, and tell me how long you’ve had them and how severely they bother you:

Do you experience other symptoms such as nervousness, fears, washing hands, excessive worry, or physical symptoms such as heart pounding, feeling faint, breathing problems. Please decribe any symptoms, their severity and how long you've had them? How do these symptoms affect your everyday life?

7. Do you have a problem with any of these: Angry outbursts/extremes of happiness or sadness/ spending beyond your means/ hoarding/ overeating/ sexual promiscuity/ driving fast/gambling/impulsive behavior? Please explain:

Do you have a problem controlling your temper, with mood extremes (happy/sad), overeating or overdrinking, fast driving or gambling or sexual promiscuity? If so explain and tell how these problems have affected you socially and/or legally. How severe is the problem and what have you done to manage these problems?

8. If you are consulting about a medical condition, chronic illness, chronic pain (dealing with the condition) please let me know your diagnosis, when you were diagnosed, what your current treatments are and if these are helping? Were you diagnosed by a family doctor or a specialist? What are your limitations and who supports/cares for you? Please try to specifically tell me your concerns and how I can help you?

If consulting about a medical disorder or chronic illness or pain, what is your diagnosis and treatments? When were you diagnosed? What are your limitations and who supports you and cares for you? Did you see a specialist for your condition? What is your primary concern?

9. Do you have close friends or relatives and if so, who is there for you?

Do you have any close friends or relatives? Who is there for you?

10. If no one is close, are you a loner by choice or do social situations make you uncomfortable? What other supports do you have available to you?

If no one is close to you, is that by choice or are you uncomfortable in social situations? Are you happy with your situation or do you want to change it? Where and how do you get support?

11. Briefly describe your childhood – was it happy/sad? Any significant problems as a child?

Briefly describe your childhood. Was it happy or sad? What made it so? And did you have any significant problems in childhood?

12. Briefly describe your family of origin. Tell me about your mother/your father and if they are living or dead? How many brothers and sisters and where were you located in the family (oldest/youngest/middle)? Who were/are you closest to in the family? Who are you most distant to and with whom do you have the most conflict?

Briefly decribe your family of origin. Tell me about your mother and father; are they living or dead? How many brothers and sisters and where were you located in the family? Oldest, youngest, in the middle. Who are you closest to, most distant from, and with whom did you have the most conflict? Why?

13. Are you currently taking any medications? Can you list them with the dosages and how often you take these medications daily? If you are on a psychiatric medication, who prescribes this for you? Please include over-the-counter medications and any herbal remedies. Are you having any side effects to these medications and what are they?

What current medications (medical/psychiatric/herbal/over the counter) are you taking? Please give dosages and times you take the medications. Are you having side effects? Describe and give severity.

14. Do you have any medical conditions I should know about (if not consulting specifically about a medical condition)? If so please describe and tell me when you were first diagnosed and your treatments. What medical or emotional/psychiatric conditions (depression/alcoholism) run in your family?

Do you have any medical problems that we should know about even if not consulting about this condition? If so describe and discuss treatments. What medical and/or psychiatric conditions run in your family (high blood pressure, depression, alcoholism)?

15. What is your past experience with mental health/psychiatric services? Have you ever seen a therapist and, if so, did it help? How? Any hospitalizations?

What is your experience with mental health services/psychiatry? Have you ever seen a therapist(s)? How many? If so, did it help? How? Any psychiatric hospitalizations? If so, why?

16. Do you have a problem with substance abuse (alcohol/drugs) – if so are you in treatment for these or use a self-help group (AA)? If not, what is the extent of your problem?

Do you have a problem with substance abuse (alcohol/drugs/food)? If so are you currently in treatment? If not,why? Also what is your specific substance of abuse and the extent of the problem? How long have you had the problem?

17. What is your basic philosophy and view on life (life is basically good/bad/or OK)? Where do you see yourself in 5 years? What will you be doing then?

What is your basic view about life? Where do you see yourself in 5 years? What will you be doing then?

18. Describe yourself to me:

Describe yourself to me. If and when you " mess up," what do you say to yourself? Do you forgive yourself or others easily? Please elaborate.

19. Describe yourself to me through a friend’s eyes—how would your closest friend describe you?

How would a friend describe you to me, especially a close friend who knew you well?

20. In the following box tell me what you believe is your main problem? Be specific.

What is your main or primary problem? Why are you seeking help? Be specific.

21. In the following box tell me how you will know when your main problem is resolved? How will PsychOptions know you have been helped?

Tell me how you will know when your main problem will be gone/resolved?

22. Tell me three (3) things you enjoy doing most in life (hobbies/sports/leisure)?

Name three (3) things you enjoy doing the most:

23. Is there anything else you want to tell me about yourself or your problem?

Is there anything else you'd like to tell me or that I should know about you?

24. Finally, why are you asking for advice/help today? Why not last week or a month ago?

Why are you seeking advice/help today? Why not last week, last month or any time before that?

Again, be sure PsychOptions has your return e-mail address and we look forward to reviewing your questionnaire, supporting, and guiding you as needed with your concerns or problem.

Just click SUBMIT and you should receive a response within 72 hours, except fridays and saturdays.

Thank you,

PsychOptions

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