Dr Juliann Mitchell

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Dr. Juliann Mitchell - Online Consultation Questionnaire

Before filling out this form, please read and understand the confidentiality agreement.

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You have the choice to by-pass the series of questions that follow. If you choose not to answer the questions it may slow the counseling process as they are designed to provide me with preliminary information about you and the symptoms you are currently experiencing. If you still do not want to answer the questions, please submit the form on the next page after reading the confidentiality agreement .

Dr. Juliann Mitchell, Ph.D.

Check any and all that apply to you currently or if you have experienced any of these in the last two weeks. Thank you. 1. Difficulty in getting your breath. 2. Choking sensation or a lump in the throat3 . Skipping, racing, or pounding of your heart 4. Chest Pain, pressure, or discomfort 5. Bouts of excessive sweating 6. Faintness, light-headedness, or dizzy spells 7. Sensation of rubbery or "jelly" legs 8. Feeling off balance or unsteady like you might fall 9. Nausea or stomach problems 10. Feeling that things around you are strange, unreal, foggy, or detached from you11. Feeling outside or detached from part or all of your body, or a floating freely 12. Tingling or numbness in parts of your body 13. Hot flashes or cold chills 14. Shaking or trembling 15. Having a fear that you are dying or that something terrible is about to happen 16. Feeling you are losing control or going insane 17. Feeling sad, blue, unhappy or "down in the dumps" 18. Feeling tired, having little energy, unable to concentrate 19. Feeling uneasy, restless or irritable 20. Sleeping or eating (too little or too much) 21. Feeling that you are not enjoying the activities that you used to 22. Feeling that you have lost interest in sex or experiencing sexual difficulties.23. Feeling that it takes you longer than before to make decisions or unable to concentrate24. Feeling inadequate, like a failure or that nobody likes you anymore25. Feeling guilty without a rational reason, or putting yourself down 26. Feeling that things always go or will go wrong no matter how hard you try 27. Feeling of not wanting to live anymore 28. Feelings of wanting to hurt yourself 29. Washing your hands after you feel you have come to close to an animal or dirty object 30. Repositioning of tablecloths or rugs because you think they are not exactly right 31. Finding it impossible for you to stop repeating (if only to yourself) a sentence already spoken 32. Finding that you cannot stop counting during certain activities 33.There any activities you cannot finish before having counted to a certain number 34. You sometimes consciously distract yourself from thoughts of hurting or killing yourself 35. Checking the cleanliness of public seats, such as those in buses or taxis, before you sit down 36. After leaving your home, you constantly have to think about whether everything is in order there. 37. You find yourself counting things for no reason?38. You check books or magazines for dog-ears and straighten them immediately 39. You often have the thought that you might get sick or go blind or crazy 40. After going to bed, you get up again to check all electrical devices? 41. You suspect that others are exploiting, harming or deceiving you 42 You persistently bear grudges and do not forget insults or injuries 43. You almost always choose solitary activities 44.You feel indifferent to praise or criticism of others 45.You experience recurrent strange day dreams or fantasies46.You experience magical thinking that influences your behavior 47. You repeatedly get into conflicts with the law 48. Before age 18, you have been cruel to people or animals 49. You have a pattern of unstable and intense relationships with others 50. You have continuous feelings of emptiness 51. You feel uncomfortable in situations where you are not the center of attention 52. You are easily influenced by others 53. You are often envious of other people54.You are often preoccupied with unlimited success or ideal love 55. You see yourself as socially inept, personally unappealing or inferior to others56. You have difficulty making everyday decisions without an excessive amount of advice and reassurance from others 57.You are preoccupied with details, rules, lists, order, organization, or schedules 58. You spend increasing amounts of online time focused on sexual or romantic or involvement59. You not consider online sexual or romantic "affairs" to be a possible violation of spousal/partnership commitments60. You have failed in attempts to cut back on frequency of online or Internet sexual and romantic involvement or interaction62. Online use is interfereing with primary relationships (e.g. minimizing or lying to partners about online activities, spending less time with family or partners)?63. You frequently become angry or extremely irritable when asked to give up online involvement to engage with partners, family or friends?64. You have experienced or witnessed a life-threatening event that caused intense fear, helplessness, or horror.65.You have repeated, distressing memories and/or dreams of the event 66. You find yourself acting or feeling as if the event was happening again (flashbacks or re-living it).67. You have intense physical and/or emotional distress when you are exposed to things that remind you of the event68. You find yourself avoiding reminders of the event and feel numb, compared to the way you felt before 69. You find yourself avoiding thoughts, feelings and conversations about the event 70. You find yourself avoiding activities, places or people who remind you of the event 71.Resulted in your failure to fulfill responsibilities with work, school or family 72. Placed you in a dangerous situation, such as driving a vehicle under the influence 73. Been responsible for you being arrested74. Continued despite causing problems for you and your loved ones

75. What would you like me to know about you? If you have any questions please ask in the box below.
I have read the confidentiality agreement. You must read and agree to these terms before proceeding. I agree

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