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Personal Information
User Name: * (Up to 12 letters and numbers)
Password: * (Up to 20 letters and numbers)
Email: *
Year of Birth:
Gender:
Marital Status:
Number of Children:
State of Residence:
Diagnosis
Please enter your diagnosis or if unknown or unclear you may list your main conditions.
Diagnosis 1:
Diagnosis 2:
Diagnosis 3:
Diagnosis 4:
Diagnosis 5:
Conditions
Condition 1:
Condition 2:
Condition 3:
Condition 4:
Condition 5:
Other Information
Year of first symptoms - first sought treatment and given diagnosis:
(whether diagnosis was accurate or not)
Year of the main diagnosis or condition you have been treated for:
Prior cumulative counseling sessions: any form of individual counseling for main diagnosis such as psychotherapy, cognitive-behavioral, or other.
Inmediate Family History of Psychiatric Problems:


Past drug or alcohol problem (greater than six months since last use):
Current drug or alcohol problem (less than six months since last use):
Privacy Options
Do we have permission to use your data for scientific research purposes?

(You will not be able to be identified. Your information will be complied with others who have given permission to understand treatments trends and responses in mental health care.)
May we contact you in the future about additional mental health research projects that may be of interest to you?