Questionnaire for New Client Your first name* Your age: Your email address:* If you live in the U.S. or Canada, your time zone:SelectPacificMountainCentralEasternIf 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?SelectYesNoIf yes, tell me a little about it:Have you had any experience with cognitive-behavioral therapy (CBT)?SelectYesNoIf yes, tell me about your experience:How healthy is your diet?SelectVery healthyBetter than averageAverage dietWorse than averageAbout 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.SelectNoneEquivalent of one cup of tea or one soft drinkEquivalent of one cup of coffeeTwo cups of coffee3 to 4 cups of coffeeMore than 4 cups of coffeeAbout how much alcohol do you drink in a typical day?SelectNoneOne drink (equal to one beer or one glass of wine)Two drinks3 to 4 drinksMore than 4 drinksDo you smoke or vape?SelectYesNoDo you do any regular exercise?SelectYesNoIf yes, tell me about it:Do you practice meditation or use a relaxation method?SelectYesNoIf yes, what do you find helpful?What is the quality of your sleep?SelectGoodSometimes good, sometimes not very goodPoorAny 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?CAPTCHA