Angelika Vraka (MA)

AllAboutYouCounselling.com

Counselling & Psychotherapy  |  Face to Face & Online

E-Counselling Client Questionnaire
Your Name (*)
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Date of Birth (*)
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Gender (*)
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Email (*)
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Home number
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Mobile number
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Occupation
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If you requesting distant services (Skype) why would that be
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What brings you to therapy
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Have you had any type of counselling before?
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Are you currently being treated by
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Are you currently taking any psychotropic medication (anti-depressants, anti-anxiety)? If so which?
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Please describe any negative feelings you might have?
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Have you ever felt suicidal or feel you might be now?
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How would you rate your experience using webcam chat or Internet messaging?
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What type of Internet connection do you have?
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How much privacy do you have for online counselling
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How would you like me to contact you?
When is the best time to contact you?
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Use the space to ask any questions you might have or if you wish to add something.
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