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Help Us Match You To The Right Therapist

Please fill out this short questionnaire to help us match you with the most suitable therapist for you, as well as give your therapist a good starting point in getting to know you.

What type of therapy are you looking for?

What is your age ?

What is your gender?

What is your current relationship status?

What led you to consider therapy today?

Over the past two weeks, how often have you lost interest or satisfaction in things you once found pleasure in?

Over the past two weeks, have you experienced a decrease in energy or felt a significant increase in fatigue?

Over the past two weeks, how often have you not felt like yourself or that you are struggling to get things right in your life or felt that you’re a disappointment to yourself and/or your family?

Are you currently experiencing any intimacy issues?

Have you experienced any thoughts of suicide or had suicidal attempts/actions?

Are you currently experiencing chronic pain and/or medical conditions?

Are you taking any prescribed medication (s)?

Do you find yourself using alcohol, drugs or prescription medication to numb the pain or help you to forget what you’re going through?

Do you identify as being religious, spiritual, faith-based?

Which religion do you identify with?

How important is it for you to be matched with a therapist who has the same belief system as you do?

Do you want to incorporate your spiritual and/or religious beliefs into your therapy sessions?

Have you ever participated in mental health therapy before?

What brings you to Elevate today?

What do you want to accomplish in your therapy session?

What kind of physical shape are you in?

How would you describe your current eating habits?

If you stop and think about your current feelings, would you say that you are feeling stressed, anxious, sad or depressed?

Have you experienced any losses that’s been difficult to deal with?

If you stop and think, over the last two weeks, have you experienced increased irritability/aggravation, difficulty handling angry emotions, or reacting without thinking?

In the past two weeks, how often have you been affected by any of these issues:

Not finding things to do that brings you joy or happiness.

In the past two weeks, how often have you been affected by any of these issues:

Feeling like you’re dragging and can’t seem to find the energy or motivation to do anything?

On the flip side, feeling like you can’t seem to slow down- you are restless, constant shaking, constant moving in motion more than what is usual for you?

In the past two weeks, how often have you been affected by any of these issues:

Feeling like you can’t get pass the negative/bad experiences that have been holding you back from being the “Best me” you can be?

In the past two weeks, how often have you been affected by any of these issues:

Have you noticed any changes in your sleep pattern:

Have you experience any family conflict that causes disruptions in your life that you would like to work through?

In the past two weeks, how often have you been affected by any of these issues:

Trouble focusing on things like reading, watching T.V. shows that you used to enjoy, studying, work?

In the past two weeks, how often have you been affected by any of these issues:

Feelings/thoughts of hurting yourself, taking your life, just going to sleep and never waking up again?

In the past two weeks, how often have you been affected by any of these issues:

The problems that you’re having, how much have they affected your work/school, taking care of things at your place or getting along with others?

In the past two weeks, how often have you been affected by any of these issues:

Not sure how to handle my choices of gender identity and/or sexuality, how to reply to people when they ask me intimate questions about being transgender, feeling pressured to justify my sexuality decisions and/or not being able to keep my sexuality private.

In the past two weeks, how often have you been affected by this issue:

Disappointing my family and friends because I don’t practice or agree with the religion/spirituality that they want me to follow

Are you currently working now?

Are you a full-time/part-time student?

Experiencing new intimacy challenges?

How often do you drink alcohol within a month?

How often have you been affected by any of these issues?

Not being able to express your emotions without getting violent, hitting something/ someone, or destroying property.

How often have you been affected by any of these issues?

Trying to find the best way to handle the stress and negative situations in my life.

How often have you been affected by any of these issues?

Trying to find the balance of work, life, and family

Have you been not satisfied, stressed, worried, uncertain, regarding the stability of your job or career

Are you struggling with finances, living from paycheck to paycheck, not making ends meet, and wanting to save money but not knowing how to do it

Are you having moments where you can’t calm yourself down, feeling scared of things that you weren’t scared of before, and/or experiencing times when you can’t catch your breath?

If you were prescribed any medications for your mental health, are you taking them recommended?

congratulations

Help Us Match You To The Right Therapist

Please fill out this short questionnaire to help us match you with the most suitable therapist for you, as well as give your therapist a good starting point in getting to know you.

Are you interested in:

What state do you live in?


What is the age of the child

What gender does the child identify with?

What is the sexual orientation of the child?


What is your relation to the child?

What is the child’s current relationship status?

What led you to consider therapy today

Need assistance in choosing and setting goals

Are you currently or ever had signs of feelings of being down, loss of appetite, lack of energy, low self-esteem, having trouble getting over a death of a loved one, pet, or moving away from family/friends?

Are you currently or ever had signs of; eating until you feel sick, feeling bad when you eat, afraid of being overweight, letting food control your life, only eating when you’re by yourself?

Are you currently or ever had signs of: not being able to pay attention, easily distracted but something that may be going on around you, high energy level and can’t calm down, do things without thinking, don’t feel like I’m doing anything wrong;

Are you currently or ever struggled with; being overly angry, hostile, acting out for no reason, just plain oh don’t want to listen or talk to adults because they make you mad (think they are the enemy)?

Are you currently or ever struggled with; saying something nice to a friend, sharing things with people, asking a friend to share something, telling someone about your good ideas?

I do the best I can but for some reason, people don’t understand when I’m trying to say what I need, want, or think should happen

Whenever there is a problem in my house it seems as if everything is always my fault; they don’t listen to me

Are you currently or ever had this problem with; respecting people, people ask me why I’m not listening, adults do like when I call them by their first?

Do you or have you ever struggled with; making friends, hanging out with people that you like doing the same kind of things with, do you get bullied or teased, do you bully or tease others?

Do you or have you ever had problems feeling like you don’t do anything right? Do you feel like you have or are currently having feelings of low self-worth, lack of confidence, don’t want to be around other kids/people, and loss of interest in activities that you use to have fun doing?

Do you or have you ever looked in the mirror and don’t like what you see?

Do you now or have you ever asked yourself; what do you wish was different in your life, what is the hardest part of your life, are you thinking about bad things happening to you, or are you focused on what might go wrong

Are you now or have you ever felt like you don’t know how to handle easy things?

Are you now or have you ever just reacted without thinking?

Sometimes I just “wild out” and do things my way. That’s the only time someone sees or hears me

Do you need help handling the feelings you get when you don’t know what to expect?

You have missed a lot of days from school/class and make up excuses why you can’t go to school/class?

Are you currently or ever had signs of feeling like you’re walking on a tight rope, trouble concentrating, trouble falling or staying asleep, or it seems as if everything is stressing you out?

Are you currently or ever had signs of feeling mad than crying, yelling, or cursing?

Are you currently or ever struggled with; grades dropping significantly, lack of interest in school or school-related activities/sports?

Help Us Match You To The Right Therapist

Please fill out this short questionnaire to help us match you with the most suitable therapist for you, as well as give your therapist a good starting point in getting to know you.

Are you interested in:

What state do you live in?


What is the age of the child

What is your gender?

What is the sexual orientation of the child?


What is your relation to the child?


Who does the child live with?


What is the child’s current relationship status?

What led you to consider therapy today

Does the child need assistance in choosing and setting goals?

Has the child ever showed signs of: feelings of being down, loss of appetite, lack of energy, low self-esteem, having trouble getting over a death of a loved one, pet, or moving away from family/friends?

Has the child ever showed signs of: eating until they feel sick, feel bad when they eat, afraid of being overweight, let food control their life, or only eat when they were by themselves?

Has the child ever showed signs of: not being able to pay attention, easily distracted by something that may be going on around them, high energy level and can’t calm down, do things without thinking, blames others for their behavior?

Has the child ever struggled with: being overly angry, hostile, acting out for no reason, just out right don’t want to listen, doesn’t talk to adults because they make them mad or think authority figures are the enemy?

Has the child ever struggled with: saying something nice to a friend, sharing things with people, asking a friend to share something, telling someone about their good ideas?

Does the child have difficulty communicating their needs, wants and ideas?

Have you ever heard the child say, “whenever there is a problem in the house it seems as if everything is always the child’s fault, and the adults don’t listen to them”?

Does the child have a problem with: respecting people or other’s property or listening and following directions given by authority figures?

Has the child ever struggled with: making friends, hanging out with people that you like doing the same kind of things with, being bullied or teased, or have they bullied or teased others?

Has the child ever made statements or felt like they don’t do anything well? Or feel like they have feelings of low self-worth, lack of confidence, social withdrawal, and loss of interest in activities that they used to have fun doing?

Has the child ever made comments that they don’t like how they look?

Does the child seem to think about the bad things happening to them or are focused on what might go wrong?

Do you feel the child does not know how to handle easy things?

Does the child react without thinking?

Does the child just “wild out” and do things their way? Thinking that’s the only time someone sees or hears them.

Does the child need help handling the feelings they get when they don’t know what to expect or during times of uncertainty?

Does the child go to school?

Has the child ever had signs of: like they are on edge and walking on a tight rope, trouble concentrating, trouble falling or staying asleep, or it seems as if everything is getting on their nerves?

Has the child ever had signs of consistent anger, resentment, crying, yelling, or cursing?

Has the child ever struggled with: grades dropping significantly, lack of interest in school or school related activities/sports?

Has the child ever experienced a serious drop in their social, emotional, or occupational functioning?

Help Us Match You To The Right Therapist

Please fill out this short questionnaire to help us match you with the most suitable therapist for you, as well as give your therapist a good starting point in getting to know you.

What state do you live in?


What is your age ?


How do you identify [pronouns]?

What is your current relationship status?

What is the status of your relationship?

What (brought you to Elevate today) led you to consider therapy today?

How do you rate your communication skills with your partner?

When you think about how you’re partner treats you regarding respect:

How satisfied are you with your current level of intimacy?

If emotional or sexual infidelity has occurred in the relationship:

How do you feel about discussing finances issues with your partner?

Both individuals value each other’s needs, wants, and desires interest are equally important

Do you and your partner have the same values in this stage of the relationship

Are you and your partner like-minded as you transition through different life stages?

Do you experience boredom in your relationship with your partner?

Are you and your partner experiencing Jealousy

If children, are a part of your relationship how satisfied are you with parenting styles

Rate your ability as a couple to resolve conflict

Does domestic violence play a role in your relationship with your partner

Do you identify as being religious, spiritual, faith-based?

Which religion do you identify with?

How important is it for you to be matched with a therapist who has the same belief system as you do?

Do you want to incorporate your spiritual and/or religious beliefs into your therapy sessions?