Hello, my name is Claudia. I am applying for a grant to start an online counseling business. Online counseling is defined as: “the provision of professional mental health services via the Internet. Services are typically offered via e-mail, real-time chat, and/or video conferencing." Because I value your input, may I ask you nine questions? Thank you. Your feedback will make a significant difference.

* 1. Have you ever used counseling services?

* 2. How would you rate your experience?

* 3. What did you like or dislike about the counselor you used?

* 4. Which type of issue did you seek help for? (Please check all that apply)

* 5. Please indicate which method(s) you feel would be preferred for treating the conditions listed below:

  E-mail Real-Time Chat Video Conferencing Not Appropriate or some other form
Eating Disorder
Grief and Loss
Hearing Loss
Highly Sensitive Person
Medical Issues
Near Death Experience
Obsessive Compulsive Disorder
Post Traumatic Stress Disorder
Relationship Problems
Substance Abuse
Tinnitus (ringing in ears/head)

* 6. Where would you look to find a counselor for yourself or someone you care about (complete appropriate boxes)?