Customer Registration

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Email *
First Name *
Last Name *
Date of Birth *
Address 1
Address 2
City
State
Country
Zip Code
Emergency Contact Name *
Emergency Contact Phone Number *
Have you had prior counseling?
If yes to previous question, when and who was your counselor?
Please list any prescription medication you are currently using.
Are you allergic to any medications?
Which medications are you allergic to?
Any family history of mental illness or substance abuse?
Have you ever attempted suicide, or planned to harm yourself?
When and where did you attempt suicide?
Do you currently have any thoughts or feelings of wanting to physically harm yourself?
If so, do you have a plan to do so?
Any harsh punishment as a child?
Any eating disorder diagnosis?
If yes, please describe any eating disorders.
Have you been sexually or physically abused?
Do you worry that you might have been abused as a child?
Describe your current usage of alcohol or drugs:
Have you been treated for substance abuse?
If yes, when were you treated for substance abuse?
Any medical history you feel is effecting your well being?
Do you have any current sleep difficulties?
Are you experiencing any current change in appetite?
Do you prefer a male or female therapist?
What goal do you have, as a result of eTherapy?
Check all the boxes that apply to you: Headaches?
Heart palpitations
Sleep problems
Want to hurt self
Want to hurt others
Hyperactive
Diabetes
Hysterectomy
Drug use
Financial problems
Incompetent
Tend to be controlling
Shy
Don't take vacations
Confused
Considerate
Handicapped
Not confident
Can't make decisions
Can't make friends
Stomach problems
Feelings of panic
Trembling
Unable to relax
Nervous
Fearful
Timid
Visual Hallucinations
Auditory Hallucinations
Inattentive
Hypoglycemia
Hormonal problems
Can't concentrate
Worthwhile
Regrets from past
Misunderstood
Sympathetic
Fairly Intelligent
Fainting spells
No appetite
Regular alcohol use
Depressed
Inadequate
Disturbing thoughts
Guilty
Hateful
Feel inferior
Bad home conditions
Memory problem
Unattractive
Bored
Restless
Delusions
Thyroid problems
Menopause
Can't keep a job
Nightmares
Empty feelings
Fatigue
Tense feeling
Sex problems
Worthless
Stupid
Evil
Overambitious
Good person
Dizziness
Attractive
Lonely
Not loved
Confident
My Timezone

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