Client Application

Please take your time to complete this, even in stages. As you progress, your information may NOT be automatically saved to the system. If you want to write out your answers in a separate document, then cut and paste your responses here, you can access a copy of the questions here. If you do not have an answer for a certain question, please input "N/A" You will automatically be sent a copy of your responses. You will also be able to edit your responses once submitted.

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Email *
First Name *
Last Name *
Today's Date *
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Phone Number *
Age *
Gender *
Sexual Orientation *
Geographic Location *
Occupation *
What kind of work are you interested in? *
Relationship Status *
Number of Marriages/Pregnancies/Children *
1. How did you hear about Teena? *
2. What types of psychotherapy or counseling have you done previously, and for how long? *
3. What were your primary reasons for seeking therapy, and what were the major issues addressed? *
4. Are you on any medications? If so, what are they, and what are they for? *
5. Have you been on prescription medications for psychological/emotional challenges? *
6. Have you ever been hospitalized for psychological/emotional disorders?
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7. Have you ever experienced a bad drug trip, and if so, what happened?
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8. Do you use tobacco, caffeine, drugs, and/or alcohol? If so, how much and how often?
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9. Have you ever had an addiction to substances, porn, sex, eating, etc.? If so, how did you work with this, and how long has it been since any active addiction?
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10. What was your religious upbringing?
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11. Current spiritual practice?
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12. Are you affiliated with a particular group or religious organization?
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13. What were the major challenges in your family dynamics as a child? (Please write at least a few paragraphs about this.) 
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14. What have the major challenges been for you as an adult? (Please write a few paragraphs about this.) 
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15. Have you experienced any type of abuse? If so, please describe.
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16. Have you ever been convicted of a crime? If yes, please describe.
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17. Have you ever attempted suicide? If yes, please describe.
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18. Any significant accidents/injuries/illnesses? If yes, please describe. 
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19. Any military service? If yes, please describe.
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20. Are you currently in an intimate relationship? If yes, for how long? Is it committed? Monogamous? Any affairs?
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21. If not currently in relationship, how long since your last one?
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22. What have been your major challenges throughout your history of intimate relationships? (Please write at least a few paragraphs about this. You don’t need to list all your past relationships, but rather the psychological/emotional challenges in the main ones.)
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23. What main things would you like to address in your work with Teena? What are you hoping will happen as a result? (Please write at least a few paragraphs about this.)
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24. What haven't I asked about that would be important for me to know about you?
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