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What is your gender?

Male

Female

Non-binary

How old are you?

What type of counseling are you looking for?

Individual counseling (for myself)

Couple counseling (for myself and my partner)

What is your relationship status?

Single

In a relationship

Married

Domestic partnership

Separated

Divorced

Widowed

Not sure

Have you ever been in counseling or therapy before?

No

Yes

How would you rate your current physical health?

Good

Fair

Poor

How would you rate your current sleeping habits?

Good

Fair

Poor

How would you rate your current eating habits?

Good

Fair

Poor

How would you rate your current financial status?

Good

Fair

Poor

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

No

Yes

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

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:Little interest or pleasure in doing things.

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:Feeling down, depression or hopeless.

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: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:Feeling tired or having little energy.

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:Poor appetite or overeating.

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

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

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: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?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

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

No

Yes

Are you currently experiencing any chronic pain?

No

Yes

Are you currently employed?

No

Yes

Do you consider yourself to be spiritual or religious?

No

Yes

Do you have any problems or worries about intimacy?

No

Yes

What is your orientation?

Straight

Gay

Lesbian

Bisexual

Not sure

Are you currently taking any medication?

No

Yes

When was the last time you had a plan to commit suicide?

Never

Over a year ago

Over 3 months ago

Over a month ago

Over a week ago

This week

How often do you drink alcohol?

Never

Infrequently

Monthly

Weekly

Daily

Who referred you to BetterHelp?

A friend or family member

My doctor

My therapist

Searched online

Saw an ad

Saw a social media post

Read a story about it

Heard about it on the radio

Other

Which country are you in?

Next

Which state are you in?

What is your preferred language?

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"I love how Leah is easy to talk to and breaks things down very easily for me. She’s great!"

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"I've really appreciated working with Rebecca. She has a lot of good insights and has helped me focus on what I need to do to make positive change in my life. "

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"Melissa was a lot of help and very comforting. I would definitely recommend her help to others. "

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"Judith is a really good listener. She is responsive and professional. I would recommend her to anyone who needs therapy."

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"Paola has been very wonderful! Very sweet, and made me feel comfortable very quickly. I am very much looking forward to our future sessions and working together on my goals!"

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