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By
joining today, you will be able to schedule appointments
with any of our staff professionals
or therapists, join our private
discussion groups and automatically be enrolled into our
monthly tape
give-away. Already registered? click
here. |
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| First
Name: |
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| Last
Name: |
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| Date
of Birth |
example format: 01/07/60 |
| Time
Zone: |
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| Email: |
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| Choose
a UserID: |
10 characters max. |
| Password: |
10 characters max. |
| Confirm
Password: |
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| Address
1 |
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| Address
2 |
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| City |
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| State/Country |
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| Zip/County/Province
Code |
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| Country |
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Insurance
companies do not generally cover eTherapy, If you plan to seek reimbursement
from your carrier, list Name and SS# of the policy holder.
Be aware that eTherapy records will be requested by the insurance
company.
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| Emergency
Contact Name and Phone Number |
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Please continue with
the following questions: |
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Have you had prior counseling? If so, when and with who? |
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Are
you currently on any medications? If so, please list what they are
used for
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Are
you allergic to any medications? If so, which ones?
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Do
you have a family history of mental illness or substance abuse?
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Have
you ever attempted suicide, or had a plan to harm yourself ? When?
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Do
you currently have any thoughts or feelings of wanting to physically
harm yourself ? If so, do you have a plan to do so?
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Have
you ever been diagnosed with an eating disorder? Describe
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Did
you experience harsh punishment as a child?
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Have
you been sexually or physically abused, or do you worry that you
might have been?
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Describe
your current usage of alcohol/drugs:
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Have
you been treated for substance abuse? When?
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Briefly
describe any medical history you feel is effecting your well being.
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Do
you have (1) current sleep difficulties, or (2) change in appetite?
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Do
you prefer a male or female therapist, and what goal do you have,
as a result of eTherapy?
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| Please
check the box in front of any word or phrase you feel applies
to you: |
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| How Did You Hear
About Us? |
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| Topics of Interests: |
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