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Mental Health Therapy

 > Mental Health Therapy

Mental Health Therapy

Kindly fill all details in the forms below so that we can help serve you better.

Applicant Details

All information you provide here is strictly confidential in accordance with the policy and ethical procedures of our organization. Be rest assured that you are always safe with us. This data takes less than 10 minutes to complete.

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Name
Employment Status
What is your sexual orientation? (pick only ONE)
What is your gender identity? (pick only ONE)
In the last 3 months, have you had or currently experiencing any significant life changes/stressor?

How often do you experience any of the following? Tick all that apply to you.

Tick all that apply to you.

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How often do you experience any of the following? Tick all that apply to you.
Loss of interest in pleasurable activities
Consistently depressed or down nearly everyday
Think that you would be better off dead or wish you were dead
Engage in any recreational drug use (such as alcohol, cigarrete, stimulants, cannabis, tramadol, codeine, cocaine, tobacco etc.)?
Actual or threaten death, sexual violence or serious injury in the past
Intense need to do away with your gender features and the desire to have the features of the other gender
Feel unworthy of love, respect, and incompetent about who you are and what you can do

How often do you experience any of the following?

Tick all that apply to you.

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Extreme mood swings/fluctuation
Extreme anxiety
Phobia
Sleep disturbance
Panic attack
Hallucination
Eating disorder *
Repetitive thoughts (e.g., Obsession)
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