Online Registration

Therapist *

Select a therapist and proceed with your registration.

Chidi Ndubueze, MHR, LPC, LADC/MH

Name *

First Name

Last Name

Gender *

Gender

Female

Male

Race/Ethnicity *

Click all that apply

White

Asian

American Indian

Black/African-American

Pacific Islander

Hispanic

Not Hispanic

Mixed

Relationship with emergency contact: *

Wife

Husband

Daughter

Son

Mother

Father

Fiance

Fiancee

Boyfriend

Girlfriend

Uncle

Aunt

Cousin

Niece

Nephew

Friend

Colleague

Other

For married and engaged couples only. Do you get physical with each other when you escalate?

Yes

No

We used to but not anymore

Tobacco user? *

Yes

No

Select which symptoms apply

Depression

Anxiety

Anger

Frustration

Difficulty sleeping

Anger outbursts

Crying spells

Negative thoughts

Isolation

Relationship difficulties

Low energy

Concentration problems

Restlessness

Hopelessness

Stress

Irrational thoughts

Shyness

Mood swings

Work problems

Confusion

Low self-esteem

Feelings of guilt

Loneliness

Worry

Indecision

Specific fear

Grief

Mourning

Poor motivation

Feelings of abandonment

Meaninglessness

Irritability

Panic

Boredom

Social withdrawal

Feeling misunderstood

Being treated unfairly

Troublesome thoughts

Disappointment

Select problem areas if applicable

Job-related problems

social or Legal Problems

Interpersonal problems

Difficulty carrying out identified roles

Academic problems

Difficulty with self-care/basic needs

What do you wish to see change/What would you like to gain through therapy?

Select from the list, at least 3 major goals you would like to accomplish in therapy:

Trauma: process and heal from traumatic experiences that have continued to impact my areas of functioning.

Communication: develop positive and effective communication skills to better my relationships.

Relationships: Develop healthy boundaries for healthy/healthier relational experiences

Self Esteem: Develop a healthy/healthier self-esteem/confidence/worth

Relationships: Resolve past hurts, develop positive and constructive problem-solving and conflict resolving skills to form a stronger bond in my relationships.

Depression: Identify and process dysfunctional or negative thought patterns regarding each situation associated with depressed feelings and ways to change the negative thought patterns into positive thought process.

Irrational Thoughts: Process ways that our thoughts, feelings, beliefs, and actions are inter-connected; be able to identify when my thoughts are irrational/false and be able to change my negative thought patterns/reframe my thoughts/change my belief about myself, others, or my circumstances.

Adverse Childhood Experiences: Process and resolve feelings of hurt, disappointment, shame, anger, resentment, bitterness, or feeling-stuck that are associated with early life experiences that still affect various areas of my functioning.

Anxiety: Identify the factors that trigger/contribute to/exacerbate my feelings of anxiety

Anxiety: Develop grounding skills/thought-stopping/healthy coping skills to significantly reduce or eradicate anxiety

Anxiety and Depression: Develop calming, relaxation, diversion activities, guided imagery, and other helpful tools to combat anxiety and depression.

Grief: Other forms of grief or secondary grief – process the loss of something that formed a significant part of my life but is no longer there.

Grief: Process unresolved or complicated grief and heal from the loss of my loved one.

Grief: Identify and process the various stages of grief as I grieve the loss of my loved one.

Codependency/Attachment Styles: Understand my attachment style and the ways that it impacts my relational dynamics. Develop a secure attachment style.

Marital: Process hidden fears, thoughts and beliefs that may trigger negative patterns of communication in our marriage.

Marital: Resolve and heal hurts that we brought into the marriage or caused each other; be able to communicate effectively; express needs and concerns to each other in ways that we are both receptive; strengthen our marriage.

Marital: Utilize the 5-Love-Language model to identify and fulfil each other’s core needs

Self-care: develop and prioritize self-care techniques and activities (emotional, physical, spiritual, etc.), to reduce stress and enhance my overall well-being.

Substance Use/Addiction/Recovery: Process and resolve co-occurring issues that might contribute to the use of substances; develop healthy coping skills that do not involve mood altering substances; develop a relapse prevention plan; incorporate a recovery program for external support.

Anger Management: Identify the factors that trigger or worsen my feelings of anger; develop healthy/healthier communication skills to utilize in expressing my needs, concerns, or expectations; develop healthy boundaries to nurture my emotional and mental wellness.

Premarital: Utilize the SYMBIS model to prepare us for a successful marriage.

Name *

First Name

Last Name

Phone

(###)

###

####

What Do You Need the Assessment For?

License is revoked or suspended due to DUI/DWI or Other Drug/Alcohol-related.

License is active and this assessment is court-ordered or suggested by your attorney but has no relevance to your driver's license status

Date *

Add a Date for your assessment. Chidi will contact you within 24 hours to confirm this date.

MM

DD

YYYY

Office Visit or Virtual Visit

Indicate below if you would prefer a virtual assessment to office visit.

Office visit

Virtual Visit/Telehealth