Client Questionnaire for Therapist Matching

Client Questionnaire for Therapist Matching

Having a personal connection with your therapist is crucial for effective therapy. The following questions will help us match you with a licensed therapist who best fits your specific needs and preferences.
1. What type of therapy are you looking for?

Individual (for myself)Couples (for myself and my partner)My Child (for my teen)Other
2. What is your gender identity?

2. What is your gender identity?WomanManNon-BinaryTransfeminineTransmasculineAgenderI don't knowPrefer not to sayOther (please specify) ___________
3. How old are you?

Under 1818 - 2525 - 4545 or more
4. How do you identify your sexual orientation?

StraightGayLesbianBisexual or PansexualPrefer not to sayQuestioningQueerAsexualI don't knowOther (please specify) ___________
5. What is your relationship status?

SingleIn a relationshipMarriedDivorcedWidowedOther (please specify) ___________
6. Which religion do you identify with?

ChristianityIslamJudaismHinduismBuddhismOther (please specify) ___________Prefer not to sayOther (please specify) ___________
7. Would you like to be matched with a therapist who provides faith-based therapy?

YesNo
8. Do you consider yourself to be spiritual?

YesNo
9. Have you ever been in therapy before?

YesNo
10. What led you to consider therapy today?
11. What are your expectations from your therapist? A therapist who...
12. How would you rate your current physical health?

GoodFairPoor
13. How would you rate your current eating habits?

GoodFairPoor
14. Are you currently experiencing overwhelming sadness, grief, or depression?

YesNo
15. Over the past 2 weeks, how often have you been bothered by the following problems?
Moving or speaking slowly or being restless:
Feeling down, depressed, or hopeless:
Trouble falling asleep, staying asleep, or sleeping too much:
Feeling tired or having little energy:
Poor appetite or overeating:
Feeling bad about yourself or that you are a failure:
Trouble concentrating on things, such as reading or watching TV:
Thoughts of self-harm or suicide:
16. How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
17. Are you currently employed?

YesNo
18. Do you have any problems or worries about intimacy?

YesNo
19. How often do you drink alcohol?

NeverInfrequentlyMonthlyWeeklyDaily
20. When was the last time you thought about suicide?

NeverOver a year agoOver 3 months agoOver a month agoOver 2 weeks agoIn the last 2 weeks
21. Are you currently experiencing anxiety, panic attacks, or phobias?

YesNo
22. Are you currently taking any medication?

YesNo
23. Are you currently experiencing any chronic pain?

YesNo
24. How would you rate your current financial status?

GoodFairPoor
25. How would you rate your current sleeping habits?

GoodFairPoor
26. Which of the following resources would be useful for you? (Select all that apply)

Support groupsTherapy journalWorksheetsGoal/habit trackingEducational webinarsOther (please specify) ___________I don't know
27. How do you prefer to communicate with your therapist?

Mostly via messagingMostly via phone or video sessionsNot sure yet (decide later)
28. Are there any specific preferences for your therapist? (Select all that apply)

Male therapistFemale therapistChristian-based therapyTherapist from the LGBTQ+ communityOlder therapist (45+)Non-religious therapistBlack therapist
29. Which country are you in? ___________
30. What is your preferred language?
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Should be Empty: