Pre-Consultation form for Dr. Amir Hossein Jalali Nadoushan

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1. What is the primary reason you are seeking therapy?

Anxiety, stress, or depression Relationship or family issues Trauma or emotional distress Other (e.g., addiction, grief, etc.)

2. What type of therapist would you prefer?

Male therapist Female therapist No preference I would like to know more about the therapists before deciding

3. What type of therapy are you most interested in?

Cognitive Behavioral Therapy (CBT) Psychodynamic Therapy Couple or family therapy Psychiatry counsulatation Not sure, I’d like the team to decide

4. Are you booking this session for yourself or someone else?

For myself As a representative for a couple As a representative for my teen As a representative for my child

5. How do you prefer your therapy sessions to be conducted?

Online video sessions Phone calls Flexible with any method

6. When was the last time you thought about suicide?

Within the past week Within the past month Within the past year It has been years

7. What are your expectations from therapy?

Listening Learn new skills or perspectives Searches the past Overcome my challenges Guidance or advice from a professional don’t know Other

8. How old are you?

9. What is your gender?

Male Female Other

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