General Questionnaire

Your first name*
Your age:
Your email address:*
If you live in the U.S. or Canada, your time zone:
If you live in another country, where do you live?
What psychological or physical conditions do you have?
What issues or goals would you like to work on?
What medications are you currently taking?
Have you tried medications in the past that you are not taking now? If yes, tell me a little about your experience.
Are you currently in therapy?
If yes, tell me a little about it:
Have you had any experience with cognitive-behavioral therapy (CBT)?
If yes, tell me about your experience:
How healthy is your diet?
About how much caffeine do you drink in a typical day? One regular cup of coffee is equivalent to two cups of tea or two caffeinated soft drinks.
About how much alcohol do you drink in a typical day?
Do you smoke?
Do you do any regular exercise?
If yes, tell me about it:
Do you practice meditation or use a relaxation method?
If yes, what do you find helpful?
What is the quality of your sleep?
Any comments to add about your sleep?
What are some of your sources of emotional support?
- Spouse or lover
- Friends & family
- Therapist
- Church, synagogue or mosque
- Online support groups
Who is in your household (single, spouse or partner, children, parents, etc.)?
What are some of your main activities during the day (work, childcare, school, etc.)?
What "big life issues," if any, do you think may be relevant? Examples of "big life issues" are: traumatic events, loss or illness of a loved one, separation or divorce, job change, or moving to a new city.
Is there anything you'd like to add?
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