First things first, what’s your name ?
(Required)
What’s your email address ?
(Required)
What's your age ?
(Required)
Please enter a number from
18
to
100
.
Gender
(Required)
Male
Female
Non-binary
Prefer not to say
Previous Experience with Counseling ?
(Required)
Yes, I have attended therapy before
No, this is my first time
How did you hear about ConsulTOpen ?
(Required)
Online Search (Google/Social Media)
Referral (Friend/Family)
University/Workplace Recommendation
Other
Primary reason for seeking therapy ?
(Required)
Anxiety or excessive worrying
Depression or persistent sadness
Trauma or past abuse
Relationship Difficulties
Low self-esteem or self-doubt
Anger management issues
Work/study stress
Other
How long have you been experiencing these issues ?
(Required)
Less than a month
1–6 months
6 months – 1 year
More than a year
How severe is the impact on your daily life ?
(Required)
Mild (occasional distress, manageable)
Moderate (interfering with routine tasks)
Severe (affecting work/studies/relationships)
Extreme (unable to function normally)
Have you been diagnosed with a mental health condition ?
(Required)
Yes(Specify)
No
Specify
(Required)
Do you experience frequent mood changes?
(Required)
Rarely
Occasionally
Frequently
Constantly
Do you experience difficulty concentrating or making decisions ?
(Required)
Yes, often
Yes, sometimes
No
Do you have frequent thoughts of self-harm or suicide ?
(Required)
Yes, often
Yes, sometimes
No
Who do you turn to for emotional support ?
(Required)
Friends
Partner/spouse
No one
What self-care activities do you engage in ? (Select all that apply.)
(Required)
Meditation or mindfulness practices
Hobbies (art, music, reading, etc.)
Socializing with friends/family
Exercise or sports
None
When facing stress, how do you usually respond ? (Select all that apply.)
(Required)
Talk to someone
Avoid the situation
Use distractions (TV, social media, etc.)
Engage in self-destructive behaviors (drugs, alcohol, etc.)
What do you expect from this session ?
(Required)
Emotional support & coping strategies
Stress management techniques
Improving communication in relationships
Dealing with past trauma
Do you have any concerns about confidentiality?
(Required)
Yes (Specify)
No
Specify
(Required)
Feedback: Is there anything else you would like to share or any suggestions for improving this questionnaire or the counseling process ?
(Required)
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