Melissa Gonzalez-Strick, MHS

Licensed Clinical Professional Counselor

Screening Form


Please answer the following questions:

Have you ever received counseling in the past? Yes No

If yes, when did you receive counseling services and what was the reason?

Did you find it helpful? Yes No

Are you currently taking any medication? Yes No

If yes, what are you taking (including dosage) and for what reason?

Have you ever received a mental health diagnosis? Yes No

If yes, what was/is the diagnosis?

Have you ever had thoughts of hurting yourself? Yes No

If yes, when did you have those thoughts? Explain:

Please indicate if you are experiencing any of the following symptoms:
Section A  
Frequent headaches
Chronic sadness
Frequent bouts of crying
Weight loss
Weight gain
Loss of appetite
Sleeping problems
Memory problems
Difficulty functioning at work
Reduced interest in activities
Feelings of worthlessness
Section B  
Feeling agitated
Excessive worry
Fear of loss of control
Racing heart
Sense of doom
Panic attacks
Shortness of breath
Avoiding public places
Avoiding social situations
Section C  
Flashbacks or reliving past negative experiences
Intrusive thoughts of bad memories
Feeling detachment from others
What is your reason for seeking online services?  
Life Coaching
Parent Coaching
Focus and Motivational Support

By submitting this form to Melissa Strick, I understand that I may or may not be accepted for on-line services. I understand that if I am not accepted it is in my best interest. If I am accepted, I understand that to receive any further contact with Melissa I must purchase an e-mail interaction in advance through PayPal. I also understand that in sending my question or situation to Melissa it is in my best interest to be as detailed as possible to ensure a thorough response. I understand that I must allow 48 hours for a response. I understand that if accepted for on-line support that I am not receiving on-line therapy or counseling and will not use this interaction as such.