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Online Support Information and Consent
Prior to our initial online session please complete the following form. If you are seeing me as a couple, each person must fill out the form. You may download the
Informed Consent to Receive Online Support Services
by
clicking here
.
*
Indicates required field
Name
*
First
Last
Email
*
May I email you at this address?
*
Yes
No
Telephone Number
*
May I call you at this phone number?
*
Yes
No
Address
*
Relationship Status
*
Single
Divorced
Partnered/Married
Separated
Dating
Widowed
Partner's name if in relationship
*
Religion (if any)
*
Sexual Orientation
*
How do you ethnically identify?
*
In general, how happy were you growing up
*
None
Somewhat
Mostly
Extremely
What type of social support do you have?
*
List ant current of past legal issues
*
PSYCHOMEDICAL HISTORY
Please describe any significant current or past medical problems and concerns
*
Please list any medications you are currently taking. Include prescription and over-‐the-‐counter medications and the dosage of each
*
Have you ever been hospitalized for a psychological difficulty?
*
Yes
No
Have you ever attempted suicide
*
Yes
No
SUBSTANCE USE
How often do you drink alcohol and how much?
*
How often and what illicit substances do you use?
*
Do you have a family history of substance and/or alcohol abuse
*
Yes
No
Have you ever been arrested for a DUI or drug arrest?
*
Yes
No
THERAPY GOALS AND MOTIVATION
Briefly describe concerns in your life and/or in your relationships that would be relevant for me to know
*
On a scale of one to ten, how motivated are you to resolve this issue?
*
By typing my name below
I hereby give my informed consent to receive online support services
. I
hav
e read the
consent for online support information
and agree to abide by its terms during our professional relationship.
I understand that I may withdraw from online support at any time.
Name
*
Date
*
Submit
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