how old are you?

less than 14

15 - 18

19 - 24

25 - 30

25 - 30

31 - 40

Whats your gender

Male

Female

What religion do you embrace?

Muslim

Christian

Yezidi

Other

Have you ever been to therapy?

Yes

No

What led you to seek consultation today?

I've been feeling depressed

I feel anxious / overwhelmed

My mood is interfering with my job / school

I can't find the purpose of my life

I am grieving

I have experienced trauma

Other

What do you expect the therapist to do?

Do you have any suicidal thoughts right now?

Explores my past

Teaches me new skills

Guide me to set goals

Proactively check in with me

I don't know

Other

Are you taking any medications?

Yes

No

Do you have any suicidal thoughts right now?

Yes

No

What method of communication do you prefer to use with the therapist?

Video Call

Voice Call