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Quick Questionnaire
To help us better understand your needs, preferences, and goals, please take a few minutes to complete this brief form. All information will be held confidential.
11
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1
Welcome to Straight Up Health! What is your full name?
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First Name
Last Name
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2
What are the pronouns you would like to go by?
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3
Who are you looking for support for?
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4
What type of services are you interested in getting started with?
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Individual Therapy
Couples Therapy
Family Therapy
Adolescent Therapy
Low Cost Therapy
Psychoeducational Assessment
Coaching
Occupational Therapy
Nutrition Services
Sleep Therapy
Meditation and Self-Inquiry
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5
What kind of concerns are you looking for support on?
*
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ADHD
Anxiety and Depression
Chronic Illness/ Pain
Eating Disorders
Sexuality and Gender Identity
Life Transitions
Stress Managements
Perfectionism
Relationship Challenges
Sleep Challenges
Trauma
Nutrition Plans
Focus and Organizational Challenges
Family Dynamics
Intimacy and Relationshps
Other
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6
Could you expand a little more on your needs regarding the support we can offer? What are your primary goals for therapy?
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7
When would you like to begin sessions?
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In the next 1-2 days
In the next week
In the next month
Just trying to gather more information right now
Other
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8
Do you have coverage with healthcare benefits?
Yes, I have insurance to see a Registered Social Worker (RSW)
Yes, I have insurance to see a Registered Psychotherapist (RP)
Yes, I have insurance to see both Registered Social Worker (RSW) and Registered Psychotherapist (RP)
I’m not quite sure what I have insurance for
No, I do not have insurance
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9
What qualities do you value in a therapist or coach when seeking support?
Someone who identities as a woman
Someone who identifies as a man
Someone who is apart of or experienced with the LGBTQ+ community
Someone who identifies as a person of colour
Someone who is a parent
I am good with anyone
Other
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10
What is the best phone number to reach you at?
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Please enter a valid phone number.
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11
And lastly, what is the best email address to reach you at?
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example@example.com
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