Cloud therapist Booking Questionnaire
Assist us in linking you with the best therapist
Cloud therapist is a digital mental health platform providing comprehensive mental health, in an accessible,
efficient and cost-effective way. Through our qualified Mental health professionals, our counselling sessions
are conducted in an ethical, private and confidential manner. Please answer the short questions below prior to your session.
What is your name and surname?
Are you looking for individual counseling, couple or group counseling?
What words would you use to define your gender identity?
-- Select --
Female
Male
I don't know
I don’t like to share
Other
What is the state of your relationship?, Single, in a relationship, Married, Divorced, Widowed, Other
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Single
Married
in a relationship
Divorced
Widowed
Other
Have you been to counseling before?
What language do you prefer to use during the counseling session?
-- Select --
English
Zulu
Xhosa
Afrikaans
Other
Why do you want to see a therapist?
-- Select --
I've been feeling down
I'm worried or overwhelmed
My mood is affecting my work/school performance
I have difficulty forming and keeping connections
I'm struggling to find meaning and purpose in my life
I'm in mourning
I've been through a lot
I want to improve my self-esteem
I want to better myself, but I'm not sure where to begin
It was a recommendation from (friend, family, doctor)
Simply Booking
Any other reasons?
Have you ever attempted any of the activities listed below to boost your mental health? Choose all that apply:
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Mindfulness/Meditation
Physical Exercise
Medication
Dietary Guidelines
Maintaining a Journal
Spiritual Guidance
Life/Relationship Coaching
None of the above
Have you adopted any of the following as a coping mechanism?
-- Select --
excessive alcohol use
Drugs
Suppression of thoughts
Denial
Violence or abusing others
Do you think about ending your life?
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Never
More often than I should
Almost a year ago
More than three months ago
Almost a month ago
More than two weeks ago
Within the previous two weeks
Do you use any medications related to your mental health right now?
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Yes
No
How satisfied are you with your present sleeping habits?
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Good
Fair
Poor
Which province are you located in?
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KZN
Gauteng
Eastern Cape
Western Cape
North West
Free State
Limpopo
Northern Cape
Mpumalanga
What is your current occupation?
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I'm a student
I'm employed
I'm unemployed
I’m a pensioner
Please share anything you would like to share in the box below:
Reason for enquiry:
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I have poor interests in important activities
I have Lost hope and courage
I struggle with Insomnia
I often feel tired
I have poor appetite
I have struggle with poor self-esteem
I struggle with concentration
I struggle with suicidal thoughts
I struggle with normal challenges of life
I often feel very anxious when confronted with normal challenges of life
I struggle with Irritability or high temper
I often experience nightmares
I tend to suppress negative thought/events
I often become paranoid or overly watchful
I feel I am disconnected from other people
I Feel guilty about the events that occurred
I Blame myself or others about the event that occurred
I am concerned with my alcohol/drug intake
I often Feel guilty due to high drug/alcohol consumption
I think I am Drug dependent
Description of the enquiry:
Date:
Time:
