About Feelings Network Questionnaire Please fill in the following information. All information will be kept confidential, as with any other communication you provide through your eTherapy sessions. Full Name (and Nickname) Date of birth: Home Address Line 1:(street address) Home Address Line  (city, state and zip) Do not send any mail: YES  or  NO Home Telephone Number: Work Telephone Number: (optional) Private Email (not shared at work or home) Confirm Email Emergency contact name and number: Insurance companies do not generally cover eTherapy, If you plan to seek reimbursement from your carrier, list Name and SS# of the policy holder. Be aware that eTherapy records will be requested by the insurance company.  How did you find out about our services? Please check only the type of sessions you have added to your private account. eMail Session(s) Chat Session(s) Phone Session(s) Please continue with  these important questions: Have you had prior counseling? If so, when? Are you currently on any medications? If so, please list what they are used for Are you allergic to any medications? If so, which ones? Do you have a family history of mental illness or substance abuse? Have you ever attempted suicide, or had a plan to harm yourself ? When? Do you currently have any thoughts or feelings of wanting to physically harm yourself ? If so, do you have a plan to do so? Have you ever been diagnosed with an eating disorder? Describe Did you experience harsh punishment as a child? Have you been sexually abused, or do you worry  that you might have been? Describe your current usage of alcohol/drugs: Have you been treated for substance abuse? When? Briefly describe any medical history you feel is effecting your well being. Do you have (1) current sleep difficulties, or (2) change in appetite? Do you prefer a male or female therapist, and what goal do you have, as a result of eTherapy?  Please check the box in front of any word or phrase you feel applies to you: Headaches Naive Memory problem Heart palpitations Nervous Unattractive Sleep problems Fearful Bored Want to hurt self Timid Restless Drug use Can't concentrate Nightmares Financial problems Worthwhile Empty feelings Incompetent Regrets from past Fatigue Tend to be Controlling Misunderstood Tense feeling Shy Sympathetic Sex problems Don't take vacations Fairly intelligent Worthless Confused Fainting spells Stupid Considerate No appetite Evil Handicapped Regular alcohol use Over ambitious Not confident Depressed Good person Can't make decisions Inadequate Dizziness Can't make friends Disturbing thoughts Attractive Stomach problems Guilty Lonely Feelings of panic Hateful Not loved Trembling Feel Inferior Confident Unable to relax Bad home conditions  Can't keep a job Please use this space to add any other information about your background that would be helpful to know, so that your therapist can best help you.  This is not the space where you write your "eTherapy Session" but just for additional  information you feel your therapist should know about you. Press the "Send to About Feelings Network" button below to send to your therapist when your have completed the questions. Your browser will be forwarded back to the page you started from. aboutfeelingsnetwork.com A Division of AboutFeelingsNetwork.com Private Counseling, Education, and Referrals Over the Internet Since 1997