Name
First Name
Last Name
Dr. Espinoza is only providing telehealth via Zoom—does this work for you?
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Yes, it does!
No, I need to continue my search for in-person therapy
What motivates you to consider therapy with me?
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In the last two weeks, how often have you felt down, depressed, or hopeless?
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Not at all
1–5 days
6–9 days
10–14 days
In the last two weeks, how often have you felt little interest or pleasure in activities?
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Not at all
1–5 days
6–9 days
10–14 days
Have you had talk therapy before? Please share your experience, including any previous diagnoses, reasons for concluding therapy, and how ending therapy was discussed with them.
*
I'm interested in...
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Short-Term Therapy: 5–12 weeks
Longer-Term Therapy: 12–24 sessions
How do you plan to cover session fees?
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Self-Pay
Out-of-Network Insurance Benefits
In-Network Insurance Benefits
In the past 2 weeks, how often have you felt nervous or anxious?
*
Not at all
1–5 days
6–9 days
10–14 days
In the past 2 weeks, how often have you been troubled by feeling unable to stop or control worrying?
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Not at all
1–5 days
6–9 days
10–14 days
Describe your relationship with alcohol and other substances.
*
How frequently in the last 7 days have you experienced shifts in mood among depression, anxiety, and anger?
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None
Some
A lot
Too much
How frequently in the last 7 days have you experienced stressful inner tension?
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None
Some
A lot
Too much
How are your key relationships going?
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Where do your problems most affect you?
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Anything else you feel I should know?
Where do you primarily gather information about psychology?
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other psychology sources
Overall, these preliminary questions...
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Helped me articulate my experiences –
Didn't make sense –
