O n l i n e   Q u e s t i o n a i r e
Please ensure that you have read the Terms & Conditions before completing this questionaire.
1. First Name:
2. Last Name:
3. Age:
4. Gender:
5. Location:
6. E-Mail Address:
7. Marital Status:
8. Occupation:
9. Have you ever been in any form of counselling, coaching or psychiatric treatment?
Yes No If so, please describe:
10. Any medical problems?
Yes No If so, please describe:
11. Any current or past psychiatric medications (e.g antidepressants, sleep aids)?
Yes No If so, please list:
12. Please let us know some information about your own background, such as your family is made up, any significant events in your childhood.
13. What concerns have led you to contact us at this time?
14. Please tell us something about the background and history of your concerns.
15. Please tell us anything else that you may think is relevant

The submission of this form indicates that you have read, and agree to, the Terms & Conditions as posted by Counselling Solutions.