Book A Session1. Full Name2. Age3. What is your gender Identity? Cis Woman Cis man Trans Woman Trans Man Non-Binary Others4. What is your Pronoun?5. Sexual Orientation Gay Lesbian Bisexual Heterosexual/Straight Pansexual Asexual Others6. What is your Occupation?7. Where are you located?8. Phone number9. Email10. Preferred Mode of Session Virtual/Online Session Physical Session 11. In the Last 3 months, have you had or currently experiencing any significant life change/stressor? Frequently Sometimes Rarely Never12. Loss of interest in pleasurable activities Frequently Sometimes Rarely Never13. Consistently depressed or down nearly everyday Frequently Sometimes Rarely Never14. Think that you would be better off dead or wish you were dead Frequently Sometimes Rarely Never15. Engage in any recreational drug use (such as alcohol, cigarrete, stimulants, cannabis, tramadol, codeine, cocaine, tobacco etc.) Frequently Sometimes Rarely Never16. Actual or threaten death, sexual violence or serious injury in the past. Frequently Sometimes Rarely Never17. Intense need to do away with your gender features and the desire to have the features of the other gender. Frequently Sometimes Rarely Never18. Feel unworthy of love, respect and incompetent about who you are and what you can do Frequently Sometimes Rarely Never19. Extreme mood swings/flunctuation Frequently Sometimes Rarely Never20. Extreme Anxiety Frequently Sometimes Rarely Never21. Phobia Frequently Sometimes Rarely Never22. Sleep Disturbance Frequently Sometimes Rarely Never23. Panic Attack Frequently Sometimes Rarely Never24. Hallucination Frequently Sometimes Rarely Never25. Repetitive thoughts (e.g, Obsession) Frequently Sometimes Rarely Never26. Tell your therapist why you are booking for session (Please feel free to express how you feel).Submit
