How old are you?

Select Age 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 +

Did you know?
Almost a fifth of older adults in the United States have experienced depression. (Geriatric Mental Health Foundation, 2008)

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What is your gender identity?

Gender plays an important role in shaping personal identity and experiences. This information will help your therapist create a more personalized approach.

Woman Man Non Binary Transfeminine Transmasculine Agender I don't know Prefer not to say Other

How do you identify?

Your answer will help your therapist create a treatment plan that respects your identity and experiences.

Straight Gay Lesbian Bi or Pan Prefer not to say Questioning Queer Asexual I don't know Other

What are your pronouns?

What is your relationship status?

Do you consider yourself to be spiritual?

Have you ever been in therapy before?

Understanding your therapeutic history helps your therapist create a more effective treatment plan. If this is your first time trying therapy, we'll provide more information about what to expect via email.

No Yes

Which of the following topics interest you the most?

What led you to consider therapy today?

This is a preliminary question to help us understand what you are going through. You will have more opportunities later on, including a blank page at the end of the questionnaire, to elaborate on your feelings and share any additional important details about yourself.

I've been feeling depressed I feel anxious or overwhelmed My mood is interfering with my job/school performance I struggle with building or maintaining relationships I can't find purpose and meaning in my life I am grieving I have experienced trauma I need to talk through a specific challenge I want to gain self confidence I want to improve myself but I don't know where to start Recommended to me (friend, family, doctor) Just exploring Other

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What are your expectations from me? I need a therapist who...

How would you rate your current physical health?

Studies show that exercise can help with depression as effectively as antidepressant medication. (Psychosomatic Medicine, 2007)

Good Fair Poor

How would you rate your current eating habits?

Are you currently experiencing overwhelming sadness, grief, or depression?

Little interest or pleasure in doing things.

Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.

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 or have let yourself or your family down.

Trouble concentrating on things, such as reading the newspaper or watching television.

Thoughts that you would be better off dead or of hurting yourself in some way.

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?

Are you currently employed?

Do you have any problems or worries about intimacy?

How often do you drink alcohol?

When was the last time you thought about suicide?

Are you currently experiencing anxiety, panic attacks or have any phobias?

Are you currently taking any medication?

Are you currently experiencing any chronic pain?

How would you rate your current financial status?

How would you rate your current sleeping habits?

Which of the following resources would be useful for you?

Is there anything else you would like to share?

This is your space to share any additional thoughts, preferences, or important details that you believe we should consider when creating your personalized therapy plan. We value your input, your responses are kept completely confidential.

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Which country are you in?

To send you your results and recommendations regarding your therapist, please fill in the field below: