Free Guidance and Support By taking a few minutes to fill out this form, you can teach me a lot about your healing path, and you can give me a great starting point in suggesting resources for you. Your information is kept strictly confidential. Your first name*Your age:Your email address:*If you live in the U.S. or Canada, your time zone:SelectPacificMountainCentralEasternIf you live in another country, where do you live?On a typical day, what is your average level of anxiety, with "0" being completely calm and peaceful, and "10" being a panic attack?In the last week, about how many panic attacks have you experienced?In the last month, about how many panic attacks?Do you believe a panic attack can be dangerous?SelectYesNoNot sureDuring a panic attack, what do you do that helps you cope?Which of the following are "triggers" for panic for you: Traveling far from home by yourself Going to a crowded restaurant Taking an elevator up 10 stories Going on an airplane trip Which of the following are among your top fears: Being embarrassed in a social situation Being watched closely when doing something Being the center of attention Do you often avoid social events or social situations?SelectYesNoTell me a little about how your activities are restricted by your condition:What do you think is your correct diagnosis?About how long ago did this condition start?What other psychological or physical conditions do you have?What medications are you currently taking?Have you tried medications in the past that you are not taking now? If yes, tell me a little about your experience.Are you currently in therapy?SelectYesNoIf yes, tell me a little about it:Have you had any experience with cognitive-behavioral therapy (CBT)?SelectYesNoIf yes, tell me about your experience:How healthy is your diet?SelectVery healthyBetter than averageAverage dietWorse than averageAbout how much caffeine do you drink in a typical day? One regular cup of coffee is equivalent to two cups of tea or two caffeinated soft drinks.SelectNoneEquivalent of one cup of tea or one soft drinkEquivalent of one cup of coffeeTwo cups of coffee3 to 4 cups of coffeeMore than 4 cups of coffeeAbout how much alcohol do you drink in a typical day?SelectNoneOne drink (equal to one beer or one glass of wine)Two drinks3 to 4 drinksMore than 4 drinksDo you smoke or vape?SelectYesNoDo you do any regular exercise?SelectYesNoIf yes, tell me about it:Do you practice meditation or use a relaxation method?SelectYesNoIf yes, what do you find helpful?What is the quality of your sleep?SelectGoodSometimes good, sometimes not very goodPoorAny comments to add about your sleep?What are some of your sources of emotional support? Spouse or lover Friends & family Therapist Church, synagogue or mosque Online support groups Who is in your household (single, spouse or partner, children, parents, etc.)?What are some of your main activities during the day (work, childcare, school, etc.)?What "big life issues," if any, do you think may be relevant? Examples of "big life issues" are: traumatic events, loss or illness of a loved one, separation or divorce, job change, or moving to a new city.Is there anything you'd like to add?CAPTCHA
