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Let's Match You with the Best Therapist!
Thank you for trusting The Emotional Wellness Initiatives with your wellness journey! Finding the right therapist for yourself can seem like a daunting task and we want to ease the pressure off of you. All you need to do is answer a few short questions below, and we'll match you with the best suited therapist for your needs!
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Email
*
Your email
Full name
*
Your answer
Your WhatsApp number?
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Parent / legal guardian name
*
Mention
NA
if you are not a minor.
Your answer
Parent / legal guardian contact no.
*
Mention
NA
if you are not a minor.
Your answer
Gender
*
Female
Male
Non binary
Prefer not to say
Relationship Status
*
Not in a relationship
In a relationship
Married
Living together
Separated
Divorced
Widowed
Other:
Occupation
*
Your answer
Your location (Town / City & Country)
*
Your answer
What are the issues for which you are seeking help?
*
Anxiety
Depression
Relationship problems
Anger
Grief and loss
Adjusting to life changes
Pregnancy and conception related emotional difficulties
Obsessive Compulsive Disorder
Other:
Required
Current symptoms
Check under 1 to 5 as per the intensity of the symptom.
5 very high - 1 very low.
Leave blank if you do not have the particular symptom.
1
2
3
4
5
Anxiety attacks
Avoidance
Change in Appetite
Unable to concentrate / forgetfulness
Crying spells
Decrease need for sleep
Decreased libido
Depressed mood
Excessive energy
Excessive guilt
Excessive worry
Fatigue
Hallucinations
Impulsivity
Increased irritability
Increased libido
Increased risky behavior
Loss of interest
Racing thoughts
Sleep pattern disturbance
Suspiciousness
Unable to enjoy activities
1
2
3
4
5
Anxiety attacks
Avoidance
Change in Appetite
Unable to concentrate / forgetfulness
Crying spells
Decrease need for sleep
Decreased libido
Depressed mood
Excessive energy
Excessive guilt
Excessive worry
Fatigue
Hallucinations
Impulsivity
Increased irritability
Increased libido
Increased risky behavior
Loss of interest
Racing thoughts
Sleep pattern disturbance
Suspiciousness
Unable to enjoy activities
Any symptom not mentioned in the above list?
*
Mention
None
if you are not facing any other symptom
Your answer
Have you ever had feelings or thoughts that you didn't want to live / suicide?
*
Yes
No
Do you currently feel that you don't want to live?
*
Yes
No
Any known medical condition
*
Your answer
Are you currently on any psychiatric medication.
*
Yes
No
Are you seeking therapy / counselling for the first time?
*
Yes
No
What do you consider to be some of your strengths?
*
Your answer
What do you consider to be some of your weaknesses?
*
Your answer
What would you like to accomplish out of your time in therapy?
*
Your answer
How did you find out about The Emotional Wellness Initiatives?
*
Instagram
LinkedIn
Facebook
Google / Internet Search
Friends or family
Doctor's referral
Leap App
Other:
Referred by?
*
Mention NA if you found us otherwise
Your answer
Is there anything else you would like to tell us to help us make a selection?
Your answer
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