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Complete Match Questionnaire

Are We a Good Fit?

Complete the form below to help me prepare for our first session.

Don't fill this out if you're human:

First Name:Last Name:

Email:Phone:

How old are you?Are you employed?

What is your gender?How do you identify?

Are you currently located in Michigan?

What brings you here?

What are your goals for treatment? (If you are seeking a space solely to ventilate, we are not a good fit. Please indicate if treatment referrals are needed.)

Are you serving an active probation and/or parole term?

If yes, what were you convicted of and how long is the term?

Have you been ordered to complete a Batterer Intervention Program (BIP)? (Please note: Love With Me is not a certified Batterer Intervention Program (BIP) and therefore, we are not a good fit. Please indicate if BIP referrals are needed.)

What is your relationship status?

How would you rate your current financial status?

Do you consider yourself to be religious and/or spiritual?

Have you ever been in therapy before?

What led you to consider therapy today?

I feel Depressed

I feel anxious

My mood is getting in the way of daily activities such as work, school, getting along with other people, etc

I struggle with building and/or maintaining relationships

I am grieving

I have experienced trauma

I am struggling to find purpose and meaning in my life

I want to increase my self-esteem and/or self-confidence

I was referred (clinician, friend, partner, etc)

I would like someone to talk to and explore issues with

I need to talk through a specific challenge

What are your expectations from your therapist?

Listend to me

Challenges my mindset/beliefs

Teaches me new skills

Explores my past

Assigns me homework

Guides goal setting

Checks in with me

Other:

Are you interested in groups?

When was the last time you thought about suicide?

Are you currently experiencing sadness, grief, or depression?

Are you currently experiencing anxiety, panic attacks, or have any phobias?

Are you currently taking any medication?

Are you currently experiencing any chronic pain?

How would you rate your current health status?

How would you rate your current eating habits?

How would you rate your current sleeping habits?

How would you prefer to communicate with your therapist?

Who referred you to Love With Me?