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

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