To provide you the best possible service, I need to understand you and your situation. Please take a few moments to respond to this questionnaire. The information you provide is confidential.

Basics

Your name:

Home address

Mobile:
Work phone:
Email:

What prompted you to contact me for consultation?

What are your goals for our work together?

About you

Like you, I am a member of various groups and subcultures, but no one can be a member of all of them. If I make a mistake and offend you, I apologize, and I look forward to learning more from you.

Birthday:

Birth sex:

Gender:

Pronoun preference:

What would you like me to know about your identity?

What would you like me to know about your orientation?

Mental health history (psychiatric treatment, psychotherapy, counseling, etc.; please include the nature of the issues you addressed in treatment)

What physical or medical conditions would you like me to be aware of?

What medications are you currently taking? (Please include prescription and over-the-counter medications, nutritional supplements, etc.)

Please tell me about your educational experiences, including programs completed and degrees/certifications earned.

Please share a few words about your lifestyle and worldview.

Please provide additional comments or relevant information.

When you have finished, please click the button below. Your responses will be sent by email to matthew@liveyourvirtue.com.