Mental Health Counseling and Psychotherapy Mental Health Counseling and Psychotherapy Warning: Please avoid using your Back Button while in this form, use the buttons below. Your contact info is Required so that I can respond to your call for help! (Use an alias [fake name] if you wish to hide your identity) Step 1 of 4 25% Disclaimer* I've read the 'Confidentiality Disclaimer' on the right. Name First Last Email* PhoneAll questions below are optional! Just provide as much information as you wish. You may leave any of the below questions blank. Remember, you may wish to reserve for later your most guarded secrets. You can assure your utmost confidentiality by saving some information for our personal-private counseling sessions!Please summarize the personal challenges you are seeking help to resolvePlease check any of the following problems that seem relevant to you Anxiety Occupational Problems Panic Anger Management Depression Compulsive Internet Use Fears or Phobias Self-Control Unwanted Habits Avoidant Behavior Unhappiness Despair Social Anxiety Abrupt Mood Changes Sexual Problems Low Self-Esteem Separation/Divorce Problems with Sleep Relationship Problems Spiritual Matters Financial Problems Work Related Stress Parenting Issues Grief and Loss Drug/Alcohol Use Trauma or Abuse Compulsive Eating Medical Health Problems Compulsive Behavior Cutting or Self-Mutilation You have likely done your best to solve the difficulties for which you seek counseling. What solutions have you tried and how well have these self-discovered personal remedies worked?If you have previously sought help for mental health or behavioral problems, what counseling methods have you explored to resolve the problems for which you are now seeking help?Can you identify repetitive patterns to your problems or “life themes” that seem important for our work?Please summarize negative thought patterns or “thinking themes” that you find disturbing. Tell me the “stories” that you use to describe your difficulties: Please describe behavioral problems that you wish to learn to resolve.Have you been previously diagnosed and treated by a psychologist, psychiatrist or other mental health professional? Please describe what has or has not worked in the past:If you have tried medications for depression or anxiety, please list these below. Let me know what seems to have been effective and what has not! Tell me about unwanted side effects and the like. Please note, I do not prescribe medications!Are you currently undergoing medical treatment? Please summarize this below and list any current treatment or prescribed medications. Have you ever been hospitalized for mental health problems?What do you want to accomplish as a result of supportive counseling or psychotherapy? Please be as specific as possible about your desired outcomes. What do you want to see happen as our work progresses?What do you predict will happen if you do not learn to resolve your current personal challenges and psychological difficulties?