Help us match you to the right online therapist.

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

What is your gender?

Hi, I'll be walking you through the process of finding the best therapist for you! We'll start off with some basic questions.

How old are you?

Did you know? Almost a fifth of older adults in the United States has experienced depression. (Geriatric Mental Health Foundation, 2008)

What is your orientation?

Do you consider yourself to be religious?

Do you consider yourself to be spiritual?

What is your relationship status?

Have you ever been in counseling or therapy before?

How would you rate your current physical health?

How would you rate your current sleeping habits?

How would you rate your current eating habits?

How would you rate your current financial status?

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

Little interest or pleasure in doing things.

Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.

Feeling down, depressed or hopeless.

Trouble falling asleep, staying asleep, or sleeping too much.

Feeling tired or having little energy.

Poor appetite or overeating.

Feeling bad about yourself - or that you are a failure or have let yourself or your family down.

Trouble concentrating on things, such as reading the newspaper or watching television.

Thoughts that you would be better off dead or of hurting yourself in some way.

How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Are you currently experiencing any chronic pain?

Are you currently employed?

Do you have any problems or worries about intimacy?

Are you currently taking any medication?

When is the last time you had a plan for suicide?

How often do you drink alcohol?

Rest assured - any information provided in this questionnaire will stay private between you and your counselor.

Who referred you to 613coaching?

Which country are you in?

What is your preferred language?

Are you currently experiencing overwhelming sadness, grief, or depression?

Which religion do you identify with?

Which radio show?

How are you related to the child?

You've completed the questionnaire!

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Latest review for:

Gregory Levine

wrote 1 day ago:

"I love Jessica! She is so sweet and understanding and totally understands my feelings when I have some complicated issues in my life with anxiety. "

Latest review for:

Gregory Levine

wrote 1 day ago:

"I love Jessica! She is so sweet and understanding and totally understands my feelings when I have some complicated issues in my life with anxiety. "

Latest review for:

Gregory Levine

wrote 1 day ago:

"I love Jessica! She is so sweet and understanding and totally understands my feelings when I have some complicated issues in my life with anxiety. "