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Prospective Client Questionnaire
 

 

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Telephone counseling is not appropriate for all situations or all problems; you can determine if telephone counseling is a good fit for you.

If you answer “Yes” or “Maybe” to any of these questions, please call for specific recommendations from the counselor because you may experience greater benefit from face-to-face (in the office) counseling services and not telephone counseling.

Your confidential responses will be sent to the assigned counselor when you press the Submit Form button. 

 

  1. Are you under 18 years of age?

    Yes
    No


  2. Do you currently have a guardian or custodian?

    Yes
    No


  3. Have you ever been diagnosed with a serious mental health problem?

    Yes
    No

     

  4. Have you ever needed psychiatric hospitalization?

    Yes
    No


  5. Have you ever been diagnosed with schizophrenia? Or paranoia?

    Yes
    No


  6. Have you ever experienced any of the following? Been in a psychotic state? Had hallucinations? Had delusions? Had thoughts that you were being followed? Or had thoughts that someone was controlling your thoughts?

    Yes
    No


  7. Are you suicidal?

    Yes
    No


  8. Do you have thoughts of harming yourself?

    Yes
    No


  9. Have you ever tried to harm yourself in any way?

    Yes
    No


  10. Do you have thoughts of harming anyone else?

    Yes
    No


  11. Have you ever physically hurt anyone including yourself?

    Yes
    No


  12. Are you currently a client of a mental health professional?

    Yes
    No


  13. Are you currently a client of a mental health professional?

    Yes
    No


  14. If you are being provided care by a psychiatrist or other physician, will you refuse to allow the CCS counselor to contact your psychiatrist or other physician"

    Yes
    No


  15. Do you refuse to agree to the Client-Counselor Agreement"?

    Yes
    No

 

Thank you for completing this important questionnaire.  Your confidential responses will be sent to the assigned counselor when you press the Submit Form button. 

 

Tell us who you are (your information will be held confidentially):

    Your name    

    Your email address or telephone number   


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