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Let's start with your contact details.
Please fill all required fields before proceeding.
Name
Email
Phone
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What type of therapy are you looking for?
Individual
Couple
Teenager
(must be >18)
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What is your gender identity?
Man
Woman
Non Binary
Trans Female
Trans Male
Prefer not to say
Other
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How old are you?
Select your age.
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99
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What is your relationship status?
Single
In a relationship
Married
Divorced
Widowed
Other
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Have you been to therapy before?
Yes
No
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What has brought you to therapy today?
Brief description
Select one or more:
I've been feeling depressed
I feel anxious or overwhelmed
My mood is interfering with my job/school performance
I struggle with building or maintaining relationships
I can't find purpose and meaning in my life
I am grieving
I have experienced trauma
I need to talk through a specific challenge
I want to gain self confidence
I want to improve myself but I don't know where to start
Recommended to me (friend, family, doctor)
Just exploring
Other
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Have you been feeling down, depressed or hopeless in the past 2 weeks?
Not at all
Sometimes
Often
All the time
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Are you currently employed?
Yes
No
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Are you currently finding it difficult to manage work, your main relationships or running your home?
Yes
No
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When was the last time you thought about suicide?
Never
Over a year ago
Over 3 months ago
Over 1 month ago
Over 2 weeks ago
In the past week
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Do you currently experience anxiety, panic attacks or phobias?
Yes
No
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Do you currently take any medication?
Yes
No
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Have you any specific preferences for your Therapist?
Male
Female
From LGBTQ+ community
Older Therapist
Therapist of Colour
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How did you find us at FeelBetterTherapy?
Social Media
Google Search
Friend or Family
Other
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What country are you located?
Select a country...
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Venezuela
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What is your flexibility around possible appointments times?
Prefer mornings
Prefer afternoons
Prefer evenings - after 5pm
I am flexible
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