Customized Resources Contact Form

Confidential Information Questions

These confidential questions are being asked to save us time on our call when we will discuss options and resources. If you’re not comfortable answering some questions, feel free to skip them.

Customized Services Contact Form

I am answering these questions for:

Myself

Loved One

Location (Town, State) and closest big city near you:

Age:

Occupation:

How long have you or your loved one had social anxiety and/or fear of public speaking?

What kinds of treatment, (e.g. individual, group, type of treatment (CBT or other)), self-help, etc. have you or your loved one tried? (If currently in treatment, please include details):

What kind of resources are you or your loved one seeking? (E.g., In-person individual or group treatment with a professional, in-person support groups, online resources, worksheets and articles specific to your needs):

Is your or your loved one’s anxiety related to most all social events (mingling, one-on-one conversations, parties)? Or, is it limited to a performance based such as fear of public speaking, and/or being the center of attention? Or both?

Are you or your loved one dealing with another anxiety disorder currently? (Panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder are the other anxiety disorders. You can find the definitions here: http://www.webmd.com/anxiety-panic/guide/mental-health-anxiety-disorders

Yes

If you answered yes to the last question, please specify the anxiety disorders:

Have you or your loved one been diagnosed with any mental health issues or think you may have another disorder? (Social anxiety often co-exists with other conditions)

Yes

Please list other conditions (e.g., depression, bipolar, schizophrenia, autism):

Which is most challenging for you currently?

How does social anxiety and/or fear of public speaking affect your/loved one’s daily life? (What important things do you think it is preventing you or your loved one from doing now?)

How often do you or your loved one experience panic attacks directly related to social anxiety and/or public speaking fear?

How motivated are you or your loved one to work on overcoming this anxiety? Scale of 0 (Not at all) to 10 (Very). If completing for a loved one, please estimate and add comments if necessary.

What is preventing you or your loved one in overcoming this anxiety?

Any additional comments?

Name

Phone

How did you find this service? (e.g. social media (please specify which one), online search, referral, news article)