Self-referral for Online Counselling
therapywithrick.com
Date
-
Year
-
Month
Day
Date
Name
*
First Name
First and last letter of last name
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred language
What brings you here...
*
What is your gender identity?
How old are you?
What is your relationship status?
Do you consider yourself to be religious?
Do you consider yourself to be spiritual?
Have you been in therapy before?
What has led you to consider therapy today?
What are your expectations from me - your potential therapist?
How did you find me?
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Are you currently experiencing anxiety, panic attacks or any phobias?
Are you currently taking any medication?
Are you currently experiencing any chronic pain?
How would you rate your current sleeping habits?
When was the last time you thought about suicide?
*
Have you made any specific plans?
*
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Over the last 2 weeks, how often have you been bothered by the following problems?
Rows
Not at all
Several Days
More than half the days
Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself
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Over the last 2 weeks, how often have you been bothered by the following problems?
Rows
Not at all
Several Days
More than half the days
Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
Submit
PHQ-9 Score (0-4 Minimal) (5-9 Mild) (10-14 Moderate) (15-19 Moderately-Severe) (20+ Severe)
GAD-7 Score (0-5 Minimal) (6-10 Mild) (11-15 Moderate) (16-21 Severe)
Should be Empty: