Contact Me Name(Required) First Last Email(Required) PhoneWhich services are you interested in? Individual Counseling Couples Counseling Briefly describe why you are seeking counseling:(Required)What is your gender?(Required) How old are you?(Required) Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.(Required) Yes No Do you feel down, depressed or hopeless?(Required) Do you have trouble falling asleep, staying asleep, or sleeping too much.(Required) Yes No Do you feel tired or lack energy?(Required) Yes No Poor appetite or overeat?(Required) Yes No Do you feel bad about yourself - or that you are a failure or have let yourself or your family down?(Required) Yes No Do you have trouble concentrating on things, such as reading the newspaper or watching television?(Required) Yes No Thoughts that you would be better off dead or of hurting yourself in some way?(Required) Yes No Do you consider yourself to be religious?(Required) Yes No Do you consider yourself to be spiritual?(Required) Yes No Have you ever been in therapy before?(Required) Yes No Are you currently experiencing overwhelming sadness, grief, or depression?(Required) Yes No Are you currently employed?(Required) Yes No How often do you drink alcohol?(Required) Daily Weekly Monthly Never When was the last time you thought about suicide?(Required) Never Within the past two weeks Longer than two weeks, but less than a month More than a month Are you currently experiencing anxiety, panic attacks or have any phobias?(Required) Yes No Are you currently taking any medication?(Required) Yes No Where in Colorado are you located?(Required) Consent(Required) I agree to the below.New Life Counseling online counseling is not an appropriate option for crisis counseling. If you are experiencing a crisis please call 911 or go to the nearest emergency room. I understand that New Life Counseling offers online counseling services for individuals and couples on an out of pocket cost; no form of insurance is accepted.
