Individual Counseling Form - Counselling Simply

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SEEKING MEDIATION?

Individual

Step 1 of 7 - What is your gender?

14%

What is your gender?

Woman

Man

Non-Binary

Prefer not to say

Other

Enter Your Age

What is your relationship status?

Single

In a relationship

Married

Divorced

Widowed

Other

Have you ever been in therapy before?

Yes

No

What led you to consider therapy today?

Depression

Anger Management

Eating Disorder

Anxiety

Grief

Sleep

Trauma

OCD

PTSD

Physical Pain

ADHD

Divorce

Alcohol

Drugs

Suicide

Other

Other

Are you currently taking any medications?

Yes

No

Email

Phone

Multiple studies have shown that depression rates have dramatically increased in recent years. Whether you are dealing with depression, marriage issues, family conflict, or other trauma, finding someone to talk to is often the first step in lessening your burden.

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