PRELIMINARY INFORMATION QUESTIONNAIRE

Full Name* This field is required.

First Name

Last Name

Gender* This field is required.

MALE

FEMALE

Other

Date of Birth* This field is required.Indicate your Date of Birth (DOB)

Date

Personal Cell Phone Number* This field is required.

Area Code

Phone Number

Is it ok to leave a voicemail?* This field is required.

YES

Is it ok to send a secure text?* This field is required.

YES

Personal Email* This field is required.

example@example.com

Is it ok to send you a secure email?* This field is required.

YES

Will you be in TEXAS during your virtual sessions with your therapist?* This field is required.

YES

Are ALL parties who will participate over the age of 18?* This field is required.

YES

How did you hear about our services? * This field is required.

What services are you seeking?* This field is required.

Individual Therapy

Intensive Therapy

Premarital Therapy (Couple)

Premarital Therapy (Group) Coming Soon!

Premarital Therapy (Self-Study) Coming soon!

Marriage/Couple Therapy

Family Therapy

Group Therapy

Coaching

Critical Incident Debriefing (Businesses only)

How do you plan to pay for therapy?* This field is required.

Insurance

EAP

Self-Pay

Responsible Third Party

What is the name of your behavioral health insurance or EAP company (if applicable)?* This field is required.

AETNA

Beacon

CURALINC

HUMANA

Optum

PHCS

United Behavioral Health

United Healthcare

Other

Self-Pay

Does your insurance cover telemental health? (Check with your insurance company before continuing).* This field is required.

YES

Does each teletherapy session participant have a computer that has a good WIFI, webcam, light source, headphone/earbuds, and mike?* This field is required.

YES

What is your level of experience with computers?* This field is required.

Basic

Intermediate

Advance

Do you have a safe, quiet place where you will not be disturbed while in the virtual therapy session?* This field is required.

YES

What is the CURRENT ISSUE that caused you to seek counseling? * This field is required.

What is the CURRENT EVENT that caused you to seek counseling? * This field is required.

Have you EVER experienced any of the following in the PAST? (CHECK ALL THAT APPLY)* This field is required.

Homicidal Thinking or Behavior

Suicidal Thinking or Behavior

Childhood Abuse or Neglect

Domestic Violence

Court/Legal Issues

Disability Leave

Mental Health Hospitalization

Substance abuse Hospitalization

NONE

Are you CURRENTLY or on a ONGOING basis experiencing any of the following ? (CHECK ALL THAT APPLY )* This field is required.

Homicidal Thinking or Behavior

Suicidal Thinking or Behavior

Childhood Abuse or Neglect

Domestic Violence

Court/Legal Issues

Disability Leave

Mental Health Hospitalization

Substance abuse Hospitalization

NONE

If you checked DOMESTIC VIOLENCE whether past or current, did this violence occur between parties currently requesting services?* This field is required.

YES

I am too sensitive to rejection.* This field is required.

YESNO

It is hard for me to take instructions from people who have authority over me.* This field is required.

YESNO

I argue with other people too much.* This field is required.

YESNO

What DAYS and TIMES are you (both or all) available to meet for a telehealth session? (CHECK ALL THAT APPLY)* This field is required.

Tuesday

Wednesday

Thursday

9:00 AM

10:00 AM

11:00 AM

12:00 PM

1:15 PM

2:15 PM

3:00 PM

4:00 PM

Not available at these times

Signature* This field is required.

Clear

Thank you for taking the time to complete this questionnaire. Based on your responses, I am unable to meet your needs. Please continue your search for a therapist.

Wishing you all the best.

PRELIMINARY INFORMATION QUESTIONNAIRE