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What is your gender?

Male

Female

Are you an English speaker?

Yes

How old are you?

Which country are you in?

Which state are you in?

What is your relationship status?

Single

In a relationship

Married

Domestic partnership

Separated

Divorced

Widowed

Not sure

Have you ever been in counseling or therapy before?

Yes

How would you rate your current physical health?

Good

Fair

Poor

How would you rate your current sleeping habits?

Good

Fair

Poor

How would you rate your current eating habits?

Good

Fair

Poor

How would you rate your current financial status?

Good

Fair

Poor

Are you currently experiencing overwhelming sadness, grief, or depression?

Yes

Please select all issues you have experienced or been concerned with recently:

Moving or speaking slowly

Trouble concentrating on simple things

Little interest in doing things

Depression

Feeling like a failure

Feeling tired or low energy

Thoughts of feeling better off dead or of hurting yourself

Anxiety or panic attacks

None of the above

Please select all issues you have experienced or been concerned with recently:

Eating habits

Trouble sleeping

Relationship problems

Worries or problems with intimacy

Concerns related to sexual orientation

Alcohol or drug addiction

Pornography addiction

Other addiction

None of the above

Are you currently taking any medication?

Yes

When was the last time you thought about suicide?

Never

Over a year ago

Over 3 months ago

Over a month ago

Over 2 weeks ago

In the last 2 weeks

Have you made specific plans for suicide?

No, it is a general thought or feeling

Yes, I have made specific plans

Faithful Counseling is made up of a network of Christian counselors, though people of all backgrounds are welcome to receive counseling with us.In order to give your counselor the right expectations, please answer a few questions about your spiritual background. How long has your faith been important to you?

Less than a year

1-3 years

More than 3 years

My whole life

Faithful Counseling is made up of a network of Christian counselors, though people of all backgrounds are welcome to receive counseling with us.Which best describes your prayer life?

I never pray

I occasionally pray

I pray daily

I pray throughout my day

Faithful Counseling is made up of a network of Christian counselors, though people of all backgrounds are welcome to receive counseling with us.Which best describes the nature of the counseling you are seeking?

Mental health counseling from a Christian perspective

Spiritual counseling on primarily faith-based matters

Holistic counseling addressing both psychological and spiritual components

Other

Faithful Counseling is made up of a network of Christian counselors, though people of all backgrounds are welcome to receive counseling with us.What are your preferences around the spiritual component of your counseling (check all that apply):

I would prefer to keep our sessions strictly clinical

I would welcome any biblical wisdom

I would be open to my counselor recommending spiritual disciplines

I would be interested in my counselor incorporating prayer into our sessions

Faithful Counseling is made up of a network of Christian counselors, though people of all backgrounds are welcome to receive counseling with us.Which podcast?

Connect with a fellow believer online within our network of licensed, professional therapists.

Answer these questions about yourself to get started.

You've completed the questionnaire!

Connect with a fellow believer online within our network of licensed, professional therapists.

Answer these questions about yourself to get started.

You've completed the questionnaire!

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