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1.
What concern has prompted you to
contact me at this point in
time?
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2. Why are you interested in online counseling
rather than traditional face-to-face counseling at this point?
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3. Have you ever been in treatment with a
therapist or counselor in the past? If so, when, and for what problem(s)? What was the result of this? Are you being
treated by a therapist, counselor, or psychiatrist now?
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4. What negative feelings or “symptoms” are you
having at this time, e.g. feeling anxious, depressed, sad, angry, frustrated,
etc.
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5. How severe would you say your symptoms are?
(e.g.
mild/moderate/severe)
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6. What have you already tried for this
problem?
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7. Have you tried anything that DOES help?
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8. Are
you currently taking any psychotropic medication? (e.g. anti-depressants or
anti-anxiety medication) If so, what type of doctor prescribed it?
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9. Have you taken any psychotropic medication in the
past?
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10. Please list all medications you are now taking,
including the dosage. Please include prescriptions, over-the-counter, herbal,
homeopathic medications and nutritional supplements:
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11. How often do you
drink alcoholic beverages? (e.g. never,
rarely, occasionally, frequently, or heavily):
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12. How often do you
use recreational drugs? (e.g. never, rarely, occasionally, frequently, or
heavily) Also, please list the drugs you use:
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13. Whom do you live with
currently?
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14. If you are married or have
a "significant other" or long-term partner, what is that person's name? How
long have you been together? Please describe your relationship.
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15. Do you have any children? If so, what are their names and ages?
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16. Do
you have any brothers or sisters? Where are you in the sibling order? (e.g.
oldest, middle, youngest) Where do they live and how do you get along with
them?
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17. Are your parents alive? Where do they live
and how do you get along with them?
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18. Do you have in-laws? Where do they live and how do you get along
with
them?
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19. How much education have you completed?
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20. If
you are a student now, what school are you in, how are your grades, and how do
you like school? If you are in college or graduate school, what is your
major?
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21. Are
you happy with your current job/career? If not, why? What jobs/careers have you
done in the past and how did you like them?
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22. How
did you find out about Robert Smith? What search engine or keywords
did you
use?
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23. How
is your health, overall? Do you have any medical problems now or in the past
that would be helpful for me to know about?
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24. If
you have chronic pain yourself or have a family member that does, what kind of
chronic pain do you/they have? Please provide me with whatever information you
can about the history of the pain problem, what treatment methods you have
tried, and what physicians you have seen.
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25. I’d
like to know about your family origin, what your childhood was like, and
anything else about what your family and life were like when you were growing
up. If your past history includes abuse of any type, please include
this.
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26. Is there anything else about you that I should
know?
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