C.

Teen Counseling
1.What type of counseling are you looking for?

Teen counseling
2.What is your gender identity?
 Woman
 Man
 Non-Binary
 Transfeminine
 Transmasculine
 Agender
 I don't know
 Prefer not to say
 Other
3. How old are you?
 Under 13
 13-14
 15-16
 17
4.How do you identify your sexual orientation?

 Straight
 Gay
 Lesbian
 Bi or Pan
 Prefer not to say
 Questioning
 Queer
 Asexual
 I don't know
 Other
If you selected an option other than straight, would you prefer a therapist who specializes
in LGBTQ+ issues?
Yes (if yes, ask: What are your pronouns? She/her, He/him, They/them, Other)
No
5.What is your relationship status?

 Single
 In a relationship
 It's complicated
6.Do your parents/guardians know that you're seeking therapy?

 Yes
 No
7.How would you rate your relationship with your parents/guardians?
 Very good
 Good
 Fair
 Poor
8.Are you currently experiencing any conflicts or problems with your
parents/guardians?
 Yes
 No
9.What are the main issues or concerns that bring you to therapy? (Select all that apply)

 School-related stress
 Social anxiety or difficulties making friends
 Family conflicts
 Depression or mood disorders
 Self-harm or suicidal thoughts
 Substance abuse
 Eating disorders or body image issues
 Trauma or abuse
 Other
10.Have you attended therapy before?

 Yes
 No
11.What are your expectations from therapy? (Select multiple options)

 Learn coping strategies for stress and anxiety

 Improve my mood and emotions
 Understand myself better
 Improve relationships with family and friends
 Address specific fears or phobias
 Other
12.How would you rate your physical health and self-care habits?

 Good
 Fair
  Poor
13.Do you engage in regular physical activity or play any sports?

 Yes
 No
14.How would you describe your eating habits?

 Healthy
 Unhealthy
 Needs improvement
15.Do you have any specific health conditions or disabilities?

 Yes
 No
16.How often do you drink alcohol or use substances?

 Never
 Infrequently
 Monthly
 Weekly
 Daily
18.When was the last time you had thoughts of self-harm or suicide?

 Never
 Over a year ago
 Over 6 months ago
 Over 3 months ago
 Within the last month
19.Are you currently experiencing anxiety, panic attacks, or phobias?
 Yes
 No
20.Are you taking any medication for mental health concerns or other health
conditions?
 Yes
 No
21.How would you rate your sleep habits?
 Good
 Fair
  Poor
22.Which of the following resources do you think would be helpful? (Select multiple
options)
 Support groups with other teens
 Therapy journal or worksheets
 Goal-setting and tracking
 Educational webinars or videos
 Other
23.Do you have a preference for the therapist's gender?2
 Female therapist
 Male therapist
 No preference
24.How do you prefer to communicate with the therapist?
 Messaging or text-based therapy
 Phone or video sessions
 In-person sessions
 Not sure yet
25.Are there any specific days or times that work best for your sessions?
 Weekdays after school
 Weekends
 Evenings
 Flexible
26.How open are you to trying new things or approaches in therapy?
 Very open
 Somewhat open
 Neutral
 Not very open
27.What country are you in, and what language do you prefer for therapy sessions?
The chatbot can then provide initial recommendations, resources, and guidance for booking
appointments with a therapist specialized in teen counselling similary