Please enable JavaScript in your browser to complete this form.Full Name *FirstLastEmail *Employment Status *EmployedSelf-EmployedUnemployedAge *What is your sexual orientation? (pick only ONE) *GayLesbianBisexualStraightPansexualAsexualQueerWhat is your gender identity? (pick only ONE) *Transgender Man (you were born female, but identify as male)Transgender Woman (you were born male, but identify as female)Cisgender Man (If you were born male, and still identify as male)Cisgender Woman (you were born female, and still identify as female)Gender Non-Binary (You do not identify as strictly a man or a woman)Intersex (you were born with sexual or reproductive anatomy that doesn't seem to fit the typical definitions of female or male)In the last 3 months, have you had or currently experiencing any significant life changes/stressor? *FrequentlySometimesRarelyNeverHow often do you experience any of the following? Tick all that apply to you. *FrequentlySometimesRarelyNeverLoss of interest in pleasurable activities *FrequentlySometimesRarelyNeverConsistently depressed or down nearly everyday *FrequentlySometimesRarelyNeverThink that you would be better off dead or wish you were dead *FrequentlySometimesRarelyNeverEngage in any recreational drug use (such as alcohol, cigarrete, stimulants, cannabis, tramadol, codeine, cocaine, tobacco etc.)? *FrequentlySometimesRarelyNeverActual or threaten death, sexual violence or serious injury in the past *FrequentlySometimesRarelyNeverIntense need to do away with your gender features and the desire to have the features of the other gender *FrequentlySometimesRarelyNeverFeel unworthy of love, respect, and incompetent about who you are and what you can do *FrequentlySometimesRarelyNeverExtreme mood swings/fluctuation *YesNoExtreme anxiety *YesNoPhobia *YesNoSleep disturbance *YesNoPanic attack *YesNoHallucination *YesNoEating disorder *YesNoRepetitive thoughts (e.g., Obsession) *YesNoTell your therapist how you are feeling right now (Optional).Submit
