1. What kind of therapy are you looking for?Individual (for me)Couple (me and my partner)Children (for my child / children)

2. What is your gender?ManWomanAnother

3. How old are you?

4. What is the civil relationship?UnmarriedIn a relationshipMarriedDivorcedWidowSomething else

5. Do you consider yourself a religious person?YesNo

6. Have you ever been in therapy before?YesNo

7. What motivates you to enter therapy now?I feel depressedI feel anxious or overwhelmedmy mood interferes with my work / school performanceit's hard for me to build or maintain a relationshipI can no longer find the purpose and meaning of my lifeI'm in painI experienced a traumaI need to talkI feel the need for a changeI want to regain my confidenceI want to improve but I don't know where to startsomething else

8. What do you expect from a psychotherapist?To know how to listenHelp me figure out my pastTeach me new toolsTo be aware of my beliefsGive me homeworkTo guide me in setting my goalsSomething elseI do not know

9. How would you rate your current physical health?ExcellentVery goodGoodPoor

10. Are you currently on medication prescribed by a psychiatrist?YesNo

11. How would you prefer to communicate?OnlineTo the officeI'm not sure now (I'll decide later)