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About
Contact
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Step
1
of 10
Therapy/Counseling Questionnaire Form
What are your needs? Let’s prepare well for you.
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“Start”
button.
Start
Would you allow your partner to join?
*
Select
Yes (couple's therapy)
No (Individual therapy)
Not sure yet (decide later)
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What is your sex?
*
Male
Female
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How old are you?
*
Select
18-25 Years
26-32 Years
33-40 Years
41-55 Years
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What is your relationship status?
*
Select
In a relationship
Married
Separated
Divorced
Widowed
Single
Polyamorous
It's complicated
Do you currently live with your partner?
*
Select
Yes
No
Is domestic violence currently an issue in your relationship?
*
Select
Yes
No
Sometimes
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Have you ever been in therapy before?
*
Select
Yes
No
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What led you to consider therapy today?
*
Improve our communication
Decide whether we should separate
Resolve conflicts and disagreements
Overcome adultery
Understand myself better
Understand my partner better
Get to a fairer workload
Reduce tension
Prevent separation or divorce
Learn “good” ways to fight
Stop hurting each other
Win back my partner’s love
Love my partner again
Discuss issues around raising kids
Improve our sex and intimacy
Divorce or separation mediation
Other
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What are your expectations from your therapist? A therapist who…
*
Listens
Explores relationship dynamics
Teaches new communication skills
Challenges my/our beliefs
Mediate in difficult situations
Explores the impacts of families of origin
Assigns homework
Guides to set goals
Proactively checks in
I don’t know
Other
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Are there any specific preferences for your therapist?
*
I prefer a male therapist
I prefer a female therapist
I prefer a therapist who provides Christian-based therapy
I prefer a non-religious therapist
I am not sure
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Which country are you in?
*
Select
Ghana
Outside Ghana
How do you prefer our service is rendered?
*
Select
Online
Face-to-Face
Both Online and Face-to-Face
What is your preferred language?
*
Select
English
Local Ghanaian language
Let us engage further.
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Terms and Conditions
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Privacy Policy & Terms and Conditions
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