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Unlocking and Optimizing Human Potentials

Home
About Us
- About Oke Chinye (CEO)
Services & Programs
- Corporate Training Solutions
- Optimal Mind Clinic
Contact Us
Employee Wellbeing Blog

Help us match you to the right therapist

The following questions are designed to help match you to a licensed therapist based on your needs and personal preferences.

Name *

First

Last

Have Therapy Email

Email *

Phone Number *

Gender

Religion

Marital Status

Current Address

Date of Birth

Age

Occupation

What is your current relationship status? [Please tick appropriately]:

Single
Engaged
Partnered
Married
Saparated
Divorced
Widowed

What brings you to therapy at this time.

Primary Reason/s for Seeking Therapy currently:

Bullying
Fears / Phobias
Career Issues
Addiction Issues
Low self esteem
Anger Management
Anxiety / Stress Coping
Feelings of Depression
Grief and bereavement issues
Marital or Relationship Issues
Obsessive Compulsive disorders
Sexual Identity Concerns
Parenting Concerns
Coping with Significant Life Change
Other (s):

Current Symptoms You Are Experiencing:

Third Choice
Physically / verbally aggressive
Overwhelming stress
Overwhelming sadness
Feel out-of-control of my emotions/actions
I am having panic feelings
Recent weight change without trying
Quick-tempered / easily irritated
I have having disturbing
dreams/flashbacks
Recent change in sleep
I feel like destroying things / property
I am very worried / fearful about something
Recent change in sexual desire
I feel impulsive / doing risky behaviors
I feel like I am detached from my own body
Recent change in energy
Easily distracted/having difficulty with focus
I am avoiding situations due to a certain fear
Lack of motivation to do much of anything
I feel I am hearing voices
I feel no one understands me
Constantly looking back with regret
I am feeling hopeless
I have obsessions that get in the way of life
I have compulsions that get in the way of life
I’m not comfortable with my body:

Others

Specific Treatment Goals for Therapy

Do you Exercise?

Yes
No

If yes, how often?

How Vigorous?

Do you take caffeine?

Yes
No

If yes, how often?

What type?

Soda
Coffee
Tea

Do you take alcohol?

Yes
No

If Yes, how often?

Do you currently live alone?

Yes
No

Have you ever attempted suicide?

Yes
No

if yes, number of times

Date of last attempt

Do you consider yourself to be religious or spiritual?

Yes
No

If yes, describe your faith or believe:

Have you experienced an event or situation in your life that you would consider traumatic?

Yes
No

If yes, briefly describe:

Any other specific information?

COUNSELING AGREEMENT

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CONSENT TO TREATMENT *

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Our Location

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