Before filling out the Client Questionnaire, please answer the following question.
Are you seriously considering suicide?
(You are required to answer this question.)
If you answered " Yes " to the above question, then online and telephone counseling is not for you. Please call the National Suicide Hotline at 1-800-784-2433, your local Suicide Hotline, or call 911. You need to get help immediately. If you are in a crisis state of wanting to take your own life, you should call the Suicide Hotline immediately. There are people there who care about you and who will offer you immediate assistance and help.
Questionnaire:
* Email Address:
* Confirm Email Address:
*Gender:
* Relationship Status:
* Have you received counseling in the past?
Please check the problem or problems below that bests describes your reason for seeking counseling.
By completeing this questionnaire, I acknowledge that I have read the Client-Counselor Consent Form and completed the Client Questionnaire Form and I agree with all of the terms and conditions stated therein:
