Gathering accurate information is crucial in providing useful assessment and feedback. To aid you in formulating your first contact and to assist us in assessing which counselor would be most appropriate to address your needs we have designed the following questionnaire.
Please send an email to: info@MyOnlineTherapy.com and include the following information.
| Demographic Information: (Required)*
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| Your name: |
| Your address: |
| Your telephone number: |
| Your email address: |
| Therapeutic Information (Optional):
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| What is the problem for which you are seeking help? |
| What have you done in the past to address it? |
| What do you hope to accomplish by entering into therapy? |
| Do you have a specific therapist with whom you wish to work? |
| Who can we thank for the referral? |
* We require a name, address and phone number for the purpose of establishing Texas residency and for safety reasons. This questionnaire will only be read by our Intake Specialist who is a licensed therapist. She will review it and then separate your Demographic Information from your Therapeutic Information. Your Demographic Information will be forwarded to our business office staff. Your Demographic Information and your Therapeutic Information will be forwarded to the therapist you have requested. If you have not requested a particular therapist, the Intake Specialist will forward your information to the most appropriate therapist on our staff based on the information you have provided. At no time will your Therapeutic Information be shared with anyone except your therapist and the Intake Specialist.
If you have questions about why we require this information or if you have privacy concerns, please feel free to contact us at info@myonlinetherapy.com.
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