First Name * Last Name * Address * City * State * - - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code * Cell Phone Home Phone Work Phone At which number do you prefer to receive messages? * Cell Home Work May I email you? * Yes No Email Address Are you currently? * Working full time Working part time College student Job hunting On medical leave Social security disability Retired Other Other - Please explain List others who reside with you, including pets. Emergency Contact * Relationship to you * Friend Family Pastor Professor Other Phone * Address Where will you likely be located for your therapy sessions? (Consider possible interruptions, privacy, and good lighting) * Have you had prior therapy? * Yes No Are you currently experiencing overwhelming feelings of sadness, grief, or depression? * Yes No If so, for how long? How is your physical health? * Very good Good Unsatisfactory Poor Do you exercise regularly? * Yes No What type of exercise? Are your nutritional choices healthy or do you tend to "eat on the run?" * Do you practice any of the following? * Meditation Visualization Yoga Write in journal Other Other relaxation technique(s)? Is there any family history of the following? Anxiety Depression Bipolar disorder Domestic violence Attention deficit disorder (ADD) Suicide or attempted suicide Alcohol abuse Drug abuse Is there a webcam on your computer? * Yes No Do you have high speed internet? * Yes No What is your comfort level with technology? * Excellent Good Still learning Brand new Do you use any of the following? Email Skype Facebook LinkedIn Do you have any questions about teletherapy? Security Code *