One Time e-Consultation/First On-going Session   

Copy/Example of Questionnaire

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This is what the one time e-consultation/first session questionnare will look like to give you the opportunity to see and review the questions before signing up for the actual session. In the actual questionnaire, you will be able to answer the questions on line in the scroll boxes provided.  You might want to print the following copy of the questionnaire if that would be helpful in preparing for the online questions. Following are twenty-four questions exactly as you will find them in the questionnaire to be submitted:

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.

Example of a scroll box:

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.

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?

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:

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:

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?

9. Do you have close friends or relatives and if so, 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?

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

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?

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?

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?

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?

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?

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?

18. Describe yourself to me:

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

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

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

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

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

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