You can always press Enter⏎ to continue
Mobile Telemental Health Services
Online Global Therapy. No Referral.
START
1
What type of counselling are you looking for?
*
This field is required.
Individual counseling (myself)
Couple counseling (myself & partner)
Teenage counselling (for my child)
Previous
Next
Submit
Press
Enter
2
What is your gender?
*
This field is required.
Male
Transgender - female to male
Female
Transgender - male to female
Gender fluid
Previous
Next
Submit
Press
Enter
3
How old are you?
Previous
Next
Submit
Press
Enter
4
What is your relationship status?
Single
In a relationship
Married
Living with partner
Divorced
Widowed
Separated
Previous
Next
Submit
Press
Enter
5
Do you need religion for life meaning and purpose?
*
This field is required.
Yes
I am atheist
No
I have spiritual views
Previous
Next
Submit
Press
Enter
6
Have you been in conselling or therapy before?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
7
Have you ever though about suicide as a solution ?
*
This field is required.
Never
Over a year ago
Over 3 months ago
Over a month ago
Over a week ago
This week
Previous
Next
Submit
Press
Enter
8
Are you currently taking any medications prescribed by a Psychiatrist ?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
9
Are you suffering of anxiety, stress or depression ?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
10
Do you have trouble sleeping ?
*
This field is required.
I have insomnia
I wake up frequently
I have nightmares
I wake up feeling tired
I have no issues
Previous
Next
Submit
Press
Enter
11
What best describes the nature of counselling you are seeking?
*
This field is required.
Religion focused
Spiritual / Holistic
Clinical Therapy
Other
Previous
Next
Submit
Press
Enter
12
Who referred you to Taqtik Health?
*
This field is required.
Social media
Family or friend
Google search
Youtube
TV Ad
Radio
Other
Previous
Next
Submit
Press
Enter
13
What Country are you currently in?
*
This field is required.
Previous
Next
Submit
Press
Enter
14
Do you have a country in mind where the Counsellor should be located?
*
This field is required.
Previous
Next
Submit
Press
Enter
15
What language would you prefer?
*
This field is required.
Previous
Next
Submit
Press
Enter
16
Anything specific you would like in a Counsellor
*
This field is required.
I prefer a male counselor
I prefer a female counselor
I prefer an experienced counselor (45+)
I prefer a counselor of my own culture / religion
I prefer a counselor LGBT friendly
Previous
Next
Submit
Press
Enter
17
Topics you wish to discuss with a counsellor. Select all that apply.
*
This field is required.
Anger Issues
Anxiety, Stress, Depression
Relationship Issues / Family conflict
Trauma and abuse
Eating Disorders
Sleeping disorders
Parenting issues
Identity issues
Coping with substance / drugs abuse
Coping with life change
Coping with grief and loss
Concentration, memory, and focus (ADHD)
Motivation, self esteem, confidence
Other
Previous
Next
Submit
Press
Enter
18
Please mark all that apply.
*
This field is required.
I an EXPAT
I am a student
I am a veteran
I am employed
I am unemployed
I run my own business
I am a freelancer
I am a housewife
Other
Previous
Next
Submit
Press
Enter
19
Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
20
Email
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
21
Phone Number
*
This field is required.
Area Code
Phone Number
Previous
Next
Submit
Press
Enter
22
Do you have any additional comments you would like to share?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
23
Lead Source
Previous
Next
Submit
Press
Enter
24
Lead Generator
Previous
Next
Submit
Press
Enter
25
Assessment Received
YES
NO
Previous
Next
Submit
Press
Enter
26
Treatment Categories
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
26
See All
Go Back
Submit