New Client Questionnaire (Adult)

Emergency Assistance

If this is an emergency, please go to your local hospital emergency department right away or call:

Crisis Line: 1-800-SUICIDE
9-1-1

Hello and Welcome!

I’m very pleased to “meet” you! And I look forward to supporting you towards better sleep. ☺

Please tell me a bit about yourself and your sleep before we get started. And do feel free to give me a call at 604-771-4444 if you have any questions or concerns about any of this! Or send me a secure online message at: mytherapyonline

Client Information

First name

Last name

Home phone number

Cell phone [if no cell, please list landline again]

Date of birth

Email address

Gender

Occupation

Marital / Partnered Status

Children

Are You 19 Years Old or Older?

Yes No

If not, I’m terribly sorry to let you know that I’m not currently able to offer this service. Please check with your doctor or school counsellor (if you have one) for ideas for other possible resources. Or let me know if you need some ideas of where to look.

Are you residing in Canada?

Unfortunately, regulations only allow me to provide services in Canada

Yes No

Are you in crisis?

For many people, the benefits of online counselling make it a perfect fit. But it is not suitable for everyone. For some situations, Internet counselling is not appropriate and you’d be better served by face-to-face counselling or other crisis resources. For example:

If you are feeling suicidal or dealing with severe mental health issues
If you are coping with psychotic experiences
If your safety is currently at risk due to domestic violence or other abuse

If you are in crisis, please call the Crisis Line at 1-800-SUICIDE or go straight to the nearest emergency room of your local hospital. In BC, 310-Mental Health: Call toll free 310-6789 (no area code needed) to access emotional support, information and resources specific to mental health and substance use issues - 24 hours a day. You might also want to speak to your doctor about possible resources and referrals in your area. Other crisis resources may be found at: http://mytherapyonline.ca/possible-drawbacks/

Please check this box to confirm that none of the above situations apply to you.

Some possible conditions that may affect having insomnia therapy

The great news is that Cognitive Behaviour Therapy for Insomnia [CBT-I] has been shown in research to be wonderfully effective at reducing insomnia and improving quality of sleep for many people! That's why it's considered the #1 recommended treatment by sleep experts around the world.

However, there are a few conditions or circumstances where it is not suitable - and some where we might need to modify the CBT-I approach. To help reduce the chance of you investing time and money into beginning this therapy if it might turn out to not be the best fit for you right now, let's go over some of the more common contraindications and obstacles to effective CBT-I. If you're not sure how any of this might apply to you, or have any questions, or just want to discuss the possibilities, please feel free to give me a call at 604-771-4444. Or send me a secure message via: https://hushforms.com/lorraine412

Have you ever been diagnosed with or do you think you may have any of the following? [Please check any that apply - and we can talk more about them].

Circadian Rhythm Sleep Disorder

If you don't have a severe diagnosis, we might still be able to proceed with CBT-I. Please contact me to discuss.

Shift Work Disorder

Depending on your situation, we might be able to proceed with CBT-I. Please contact me to discuss.

Uncontrolled Seizure Disorder

Note: I may be offering a modified CBT-I in the near future. Let me know if you're interested.

Bipolar Disorder

Note: Sometimes CBT-I is not suitable with Bipolar Disorder, and sometimes adjustments can be made. Please contact me to discuss.

Current Active Alcohol and Drug Use Disorder

Unfortunately, you may not be able to benefit from CBT-I because drug and alcohol use can cause insomnia and poor sleep quality.

PTSD

It's possible that you may benefit from first receiving treatment for PTSD before beginning CBT-I. Please contact me to discuss.

Untreated Sleep Apnea

If your sleep apnea is currently being successfully treated [e.g. with CPAP], we can likely go ahead with CBT-I. If you suspect you might have sleep apnea, but haven't been diagnosed, it could be important for you to be assessed, diagnosed and treated as soon as possible. Please call me to discuss.

Comments about anything in the above check list?

Fees

Unless otherwise agreed, fees, including all applicable taxes, are $120.00 Canadian per 50 minute session or $144 per 60 minute session, and are pro-rated at $2.40 per minute for shorter or longer sessions if applicable [as per Recommended Fee Schedule of BC Association of Clinical Counsellors].

If you are unable to afford the regular fee, I do my best to offer a sliding scale, when possible.

Would you like to request a reduced sliding scale rate?

Yes No

If yes, please tell me a little about your financial circumstances and how much you can afford.

If you have an extended health plan: Many employers provide coverage for the services of a Registered Clinical Counsellor (RCC). This is between you and your extended health plan, so you may wish to confirm with them that they cover these services from a Registered Clinical Counsellor, as you’ll need to pay for the counselling session yourself and then request reimbursement from them.

Please let me know if you would like an official receipt for this purpose.

Yes No

How would you like me to contact you?

Phone #

E-mail [*Please double check accuracy!]

Please note that when I reply to an email, you'll receive a message telling you to click on a link that takes you to a secure web based message system. This is to help protect your privacy. Please add lorraine@mytherapyonline.ca to your contacts to avoid my message ending up in your spam folder.

Is it okay for me to leave a confidential voice message if you don't answer when/if I call?

Yes No

How did you hear about this service?

Please tell me more about your sleep

Please check any of the following problems that you experience:

Difficulty falling asleep at beginning of night

Difficulty staying asleep

Waking up too early

Difficulty waking up when you want to

Non-refreshing sleep

Which of the above is [are] your biggest problem[s]?

How many nights per week do you have problems sleeping?

When did this current problem start?

Please tell me more about what you think might have started your problems with sleeping. What was going on in your life at the time?

What (if any) treatment have you had for your current sleep problems [prescription, psychotherapy, etc]?

How do your problems with sleep affect you during the day?

Energy / fatigue

Daytime sleepiness

Concentration / ability to function

Mood

Other [please explain below]

Other daytime effects of insomnia:

How old were you when you first started having insomnia?

Please tell me more about your problems with sleep over the course of your life

Bedtime routine

For the following questions, please think about your most recent *typical* week. And specify if and how different on weeknights versus weekends.

What time do you usually get into bed?

What time do you usually turn off the lights [in order to fall asleep]?

How do you decide when to go to bed [e.g. clock, partner, sleepy, etc]

How do you spend your time in the hour or so before bed?

Do you have increased fears or anxiety around bedtime? Please explain.

Do you doze off in the evenings?

How long does it take you to fall asleep?

What happens when you can't get to sleep? What kinds of things do you do, or think about?

Check any that apply:

Do you worry about sleep?

Do you worry about things in general?

Do you ruminate? [go over the same thoughts over and over]

Do you feel tension in your body?

Middle of the Night

Once you get to sleep, how many times do you wake up?

How many minutes [or hours] are you awake overnight, in total?

What happens when you can't sleep in the night? What kinds of things do you do, or think about?

When you can't sleep in the night:

Do you worry about sleep?

Do you worry about things in general?

Do you ruminate? [go over the same thoughts over and over]

Do you feel tension in your body?

End of the Night

What time do you wake up for the last time at the end of the night?

What time do you get out of bed?

Is your final awakening earlier than you planned? If yes, by how many minutes?

How much sleep do you get each night on average?

Do you have a hard time waking up when you need or want to?

Yes No

How do you wake up? [e.g. set alarm clock? other?]

Sleep / Insomnia History

Please tell me more about your sleep before you started having insomnia? What was your sleep schedule? What time did you usually go to bed and finish sleeping? etc.

Medications

Medications you're currently taking for sleep. Please include dose, how long taken, time taken, whether helpful for sleep.

Other medications currently taken? [as some side effects might affect sleep]

Napping

Are you able to nap if given the opportunity?

Yes No

How often do you nap?

How long do you nap for?

What time do you nap?

Sleep Environment

Please tell me more about your sleep environment and things that might disrupt your sleep: pets? bed partner? noise? lights? temperature? anything else?

Do you feel safe at night? Or while getting ready for bed? Or ...? If not, please explain more.

Other things that can affect sleep.

Please mention time, frequency, amounts.

Caffeine

Nicotine

Alcohol

Recreational drugs

Vigorous exercise

Night-time eating

Supplements (please list any supplements taken)

Overall activity level

Understimulated

Overstimulated

Anything else you'd like to share that might be related to your sleep?

Sleep Preferences

If you could go to bed and get up at any time you like, would you sleep well? In an ideal world, what would be your ideal bed time and waking time?

Do you consider yourself a night owl?

Yes No Not sure

Do you consider yourself a morning person or early bird?

Yes No Not sure

Breathing and snoring

Do you snore? Loudly?

Do you often feel tired and unrefreshed, even after enough sleep time?

Do you choke or gasp for air or stop breathing during sleep? Has anyone ever told you that you do?

Do you have High Blood Pressure?

Please check all that apply:

Do you wake up with headaches?

Do you get up to go to the bathroom more than twice in the night?

Do you wake up with dry mouth?

Do you have high blood pressure?

What is your weight and height? [This can be relevant to risk factors for sleep apnea]

Do you fall asleep during situations that most people would not? For example: while talking with others? driving? standing? other? Please explain.

Do you sometimes have a very strong urge to move your legs? Unpleasant sensations in your legs? Please describe. When is it worst? What helps? Does it affect your ability to sleep?

Nightmares

Do you have recurring nightmares? If so, please tell me a bit more.

Goals

Please prioritize your goals for insomnia therapy.

Thank you!

Looking forward to talking to you! :)

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New Client Questionnaire (Adult)

Emergency Assistance

Hello and Welcome!

Client Information

Are you residing in Canada?

Are you in crisis?

Some possible conditions that may affect having insomnia therapy

Fees

How would you like me to contact you?

Please tell me more about your sleep

Bedtime routine

Middle of the Night

End of the Night

Sleep / Insomnia History

Medications

Napping

Sleep Environment

Other things that can affect sleep.

Sleep Preferences

Breathing and snoring

Nightmares

Goals

Thank you!

Signature

Emergency Assistance

Lorraine Irlam, M.A., RCC

Registered Clinical Counsellor, My Therapy Online