Pre-Screen Questionnaire | Tele Connect

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Pre Screen Questionnaire

Help us get to know you better, complete the form below to access the consult calendar.

First Name

Middle Initial

Last Name

DOB:

Age

Phone

Email

What is the best way to contact you? (Select one): *

Direct Cell

Only Whatsapp

Email

Home Line

Do you have access to the internet for video calls? *

Yes

No

Presenting Concern (Reason for appointment):

How long has the problem lasted? (length of time):

Have you been diagnosed with a mental health issue?

Have you received counselling for this issue in the past?

Yes

No

If yes, when was your last therapy session?

Do you have health insurance?

Yes

No

If yes, who is your service provider?

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