MOMMY-MUSE.COM CLIENT QUESTIONNAIRE   First Name * Last Name * Gender * Age * Marital Status * Email address * Retype email address * Street Address, City, State, Zip Code (for emergency use only) * Important note: Please begin with the first three (YES/NO) questions, below. (If you answer YES to any of the first three questions, then online counseling is NOT appropriate for you at this time.) If you answer NO to the first four (YES/NO) questions, then continue filling out the rest of the questionnaire. A) Have you currently had any serious thoughts about committing suicide? * Yes No If yes, please do one of these right now: • Call your local suicide hotline by dialing 911. • Go directly to your local hospital’s emergency room. • Call this toll-free number: 1-800-SUICIDE (1-800-784-2433) and you will be connected to a certified crisis center closest to your calling location, staffed twenty four hours a day, seven days a week by highly trained crisis line workers. Feelings of suicide are not chosen. Suicidal thoughts and feelings usually occur when one’s experience of psychological pain exceeds one’s resources for coping with it. Suicidal thoughts, feelings and impulses are most often due to untreated or under treated clinical depression. Fortunately, depression responds very well to treatment and suicide is now preventable. Please take time now to get professional help. B) Are you in the midst of a serious emotional crisis right now? If so, we suggest that you contact a mental health professional in your local area. * Yes No C) Do you have serious or intense emotional problems? If so, we suggest that you contact a mental health professional in your local area. * Yes No D) Are you under 18 years old? If so, we would need written consent of a parent or guardian in order to work with you. Please have your parent or guardian contact us directly. * Yes No Please take all the space you need. The boxes will expand. 1) What goal or concern has prompted you to contact me at this point in time? * 2) If you could have the most perfect outcome from our work together, what would that be? * 3) What is your baby's name, age and gender? (If you have more than one baby, please tell about each one.) 4) Please tell us about your birthing experience, adoption experience, or (if you are a stepparent) tell us about your initial relationship with your stepchild or stepchildren. 5) How much uninterrupted sleep do you get each night? 6) Have you recently felt scared and panicky for no very good reason? 7) Have you recently felt worried and anxious for no very good reason? 8) Have you recently felt extremely unhappy? 9) Have you been extremely fatigued? 10) Are you able to laugh and see the funny side of things? 11) Do you look forward with enjoyment to upcoming experiences? 12) Do you blame yourself more than you should when things go wrong? 13) Do you sometimes think of harming yourself? 14) What negative feelings or “symptoms” (if any) have you experienced recently, e.g. feeling anxious, depressed, sad, angry, frustrated, exhausted, etc? 15) If you have had recent negative feelings or “symptoms,” how severe would you say these have been? (e.g. mild/moderate/severe) 16) Are you being treated by a therapist, counselor, or psychiatrist now? In the past? 17) Have you tried anything that DOES help? If so, what? 18) Are you currently taking any psychotropic medication (e.g. anti-depressants or anti-anxiety medication)? If so, what are the medications, and what type of doctor prescribed it or them? 19) Is there anything else about you, your baby, your partner or family that we should know? 20) How did you find out about Mommy-Muse? Were you referred by a friend or doctor? Or did you see an ad or brochure? If you used a search engine, what keywords did you use? Important Note: By returning this questionnaire, I acknowledge that I have read the Client-Counselor Consent Form and agree with all of the terms and conditions stated therein.