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Client Profile

First Name*
Last Name*
Username*
Email*
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Password*
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1. What issues are you facing at the moment?
- Select All
- Bereavement
- Disability
- Obsessive Compulsive Disorder (OCD)
- Relationship Issues
- Abuse and violence
- Bullying
- Eating Disorders
- Phobias
- Self Esteem
- Addiction
- Dealing with Illness
- Family Issues
- Post Traumatic Stress Disorder (PTSD)
- Sexual Issues
- Anger Management
- Dementia
- Identity Issues
- Pregnancy
- Stress
- Anxiety
- Depression
- Infertility
- Psychosis
- Work Issues
- Attention-Deficit Hyperactivity Disorder (ADHD)
- Developmental Issues
2. How long have you been experiencing these issues?
- less than a year
- more than a year
3. How do these issues affect your daily life?
- No influence
- Little influence
- Some influence
- Strongly
- Very stongly
4. Have you seen a therapist before?
- Yes
- No
5. Would you prefer your therapist to be:
- Female
- Male
- I don’t mind
6. Anything else you want to add? (500 word limit)
*
- I am 18+ years old
*
- I agree with feelya's Terms and Conditions

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