AssessmentStep 1 of 362%How do you identify? Woman Man Non Binary Transfeminine Transmasculine Agender I don’t know Prefer not to sayWhat are your pronouns? She/her He/him They/them OtherWhat is your orientation (select all that apply)? Straight Lesbian Gay Bisexual Questioning Pansexual Queer Asexual I don’t know OtherHow old are you?Select your age131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899What is your relationship status? Single In a relationship Married Domestic partnership Separated Divorced Widowed Not sureHave you ever been in therapy before? No YesHow would you rate your current physical health? Good Fair PoorHow would you rate your current sleeping habits? Good Fair PoorHow would you rate your current eating habits? Good Fair PoorHow would you rate your current financial status? Good Fair PoorAre you currently experiencing overwhelming sadness, grief, or depression? No YesOver the past 2 weeks, how often have you been bothered by any of the following problems:Little interest or pleasure in doing things. Not at all Several days More than half the days Nearly every dayMoving 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. Not at all Several days More than half the days Nearly every dayFeeling down, depressed or hopeless. Not at all Several days More than half the days Nearly every dayTrouble falling asleep, staying asleep, or sleeping too much. Not at all Several days More than half the days Nearly every dayFeeling tired or having little energy. Not at all Several days More than half the days Nearly every dayPoor appetite or overeating. Not at all Several days More than half the days Nearly every dayFeeling bad about yourself – or that you are a failure or have let yourself or your family down. Not at all Several days More than half the days Nearly every dayTrouble concentrating on things, such as reading the newspaper or watching television. Not at all Several days More than half the days Nearly every dayThoughts that you would be better off dead or of hurting yourself in some way. Not at all Several days More than half the days Nearly every dayHow difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficultAre you currently experiencing anxiety, panic attacks or have any phobias? No YesAre you currently experiencing any chronic pain? No YesAre you currently employed? No YesDo you consider yourself to be religious? No YesDo you consider yourself to be spiritual? No YesDo you have any problems or worries about intimacy? No YesAre you currently taking any medication? No YesWhen was the last time you thought about suicide? Never Over a year ago Over 3 months ago Over a month ago Over 2 weeks ago In the last 2 weeksHow often do you drink alcohol? Never Infrequently Monthly Weekly DailyHow comfortable are you with your identity? Not at all A little comfortable Somewhat comfortable Very comfortableHow much of your LGBT+ identity is contributing to your mental health concerns? Not at all Contributing a little bit Somewhat contributing Contributing a lot Solely contributingDo you prefer to be matched with a therapist in the LGBT community? Yes No No PreferenceWho referred you to Pride Counseling? Friend or family member Social media post YouTube Google search Magazine or newspaper OtherWhich country are you in?AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCyprusCzech RepublicDemocratic Republic of CongoDenmarkDisputed TerritoryDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFederated States of MicronesiaFijiFinlandFranceFrench GuyanaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island and Mcdonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIraqIraq-Saudi Arabia Neutral ZoneIrelandIsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Occupied TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint Helena and DependenciesSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South Sandwich IslandsSouth KoreaSpainSpratly IslandsSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUS Virgin IslandsUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweWhat is your preferred language?EnglishAfrikaansAkanAmerican Sign LanguageArabicBengaliCroatianEweFrenchGermanGreekGujaratiHaitian CreoleHausaHebrewHindiIgboItalianJapaneseKikuyuKoreanMalayalamMandarinPolishPortuguesePunjabiRussianSerbianSpanishSwahiliSwedishTwiUkrainianUrduYorubaPlease mark all that apply English Afrikaans Akan American Sign Language Arabic Bengali Croatian Ewe French German Greek Gujarati Haitian Creole Hausa Hebrew Hindi Igbo Italian Japanese Kikuyu Korean Malayalam Mandarin Polish Portuguese Punjabi Russian Serbian Spanish Swahili Swedish Twi Ukrainian Urdu YorubaPlease mark all that apply I’m a student I’m a veteran I’m disabled I’m unemployed I’m employed but my income is low I’m financially impacted by the Coronavirus outbreakEnter Your DetailsEnter your nicknameEnter your email
PrideMantra
