BNM

Please fill out this short questionnaire to provide some background information about you and the issues you'd like to deal with in therapy. It would help us match you with the most suitable therapist for you. Your answers will also give this therapist a good starting point in getting to know you.

What type of therapy are you looking for?

Individual(for myself)

Couples( for myself and my partner)

Teens( for my child)

What is your gender identity?

Woman

Man

Non Binary

Transfeminine

Transmasculine

Agender

I don't know

Prefer not to say

Other

How do you identify?

Straight

Gay

Lesbian

Bi or Pan

Prefer not to say

What is your relationship status?

Single

In a relationship

Married

Divorced

Widowed

Other

Which religion do you identify with?

Christianity

Judaism

Islam

Other

Would you want to be matched with a therapist who provides religious-based therapy?

Yes

Do you consider yourself spiritual?

Yes

Have you ever been to therapy before?

Yes

What are your expectations from your therapist? A therapist who...

Listens

Explores my past

Teaches me new skills

Challenges my beliefs

Assigns me howework

Guides me to set goals

Proactively checks in with me

Other

I don't know

Are you currently experiencing anxiety ,panic attacks or have any phobias?

Yes

Are you currently taking any medication?

Yes

How would you rate your current physical health?

Good

Fair

Poor

Over the past 2 weeks, how often have you been bothered by any of the following problems:

(a) Trouble falling asleep, staying asleep or sleeping too much

Not at all

Several Days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by any of the following problems:

(b) Trouble concentrating on things, such as reading the newspaper or watching television

Not at all

Several Days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by any of the following problems:

Not at all

Several Days

More than half the days

Nearly every day

How often do you drink alcohol?

Never

Infrequently

Monthly

Weekly

Daily

How do you prefer to communicate with your therapist?

Mostly via messaging

Mostly via phone or video sessions

Not sure yet(decide later)

Are there any specific preferences for your therapist?

You can select multiple options or no

Male therapist

Female therapist

Christian-based therapist

Therapist from the LGBTQ+ community

Older therapist (45+)

Non-religious therapist

Therapist of color

What brings you here?

Which country are you in?

Which language do you prefer?

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Help us match you to the right therapist

What type of therapy are you looking for?

What is your gender identity?

How do you identify?

What is your relationship status?

Which religion do you identify with?

Would you want to be matched with a therapist who provides religious-based therapy?

Do you consider yourself spiritual?

Have you ever been to therapy before?

What led you to consider therapy today?

What are your expectations from your therapist? A therapist who...

Are you currently experiencing anxiety ,panic attacks or have any phobias?

Are you currently taking any medication?

How would you rate your current physical health?

Over the past 2 weeks, how often have you been bothered by any of the following problems:

Over the past 2 weeks, how often have you been bothered by any of the following problems:

Over the past 2 weeks, how often have you been bothered by any of the following problems:

How often do you drink alcohol?

How do you prefer to communicate with your therapist?

Are there any specific preferences for your therapist?

I prefer a therapist with experience in?

What brings you here?

Which country are you in?

Which language do you prefer?

Create an account to continue

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