Second Opinion Service
Submission Form

If you want a second opinion about a mental health or life issue you're grappling with, please fill out the below form accurately and completely. If a field doesn't make sense to you or your particular problem, just leave it blank. You must provide a valid e-mail address, or we have no way of getting back to you. This form will take about 5-10 minutes to fill out. The more information and details you provide, the more accurate and helpful your second opinion will likely be.

John Grohol, Psy.D. will read your responses in email and get back to you within the time specified below. The sooner you request a reply, the higher the price you pay. If John Grohol doesn't get back to you within the specified time period, the response will be given at no charge.

Please note, no submissions will be answered without an accompanying payment, the instructions for submitting are on the next page (after completing this form). All credit cards and e-checks are accepted through our payment service, PayPal.

Your Name:
Your E-mail address:
Reply needed within:	24 hours ($19.95), 12 hours ($29.95), or 4 hours ($44.95)
All the information below is to be filled out about the person the second opinion is for.
Person's Name:
Age:
Gender:	Female or Male
City:
State (or Country if not USA):
Occupation:
Marital/relationship status:	Single Married Separated Divorced Widowed
General summary of problem:
A description of current problem, how long it has been experienced by person, and anything that may have happened right before problem took place:
General information about person's life now, relationships with family and friends:
Specific question(s) needing addressed by second opinion:
Important Notice - Please Read! The information provided by John Grohol is for educational purposes only, in the service of providing a second opinion based upon subjective information provided to John Grohol by a third-party. The information may therefore be limited in value. While we believe the information presented will be accurate and useful, no warranties, expressed or implied, are made about the value of the advice or service given, and Psych Central and John Grohol assume no responsibility in how this information is used by the recipient. Please check with a mental health professional in your community if you suspect your problem is severe and warrants immediate attention. This is not a crisis counseling service, nor does it substitute for getting immediate assistance in the real world if you are in need of help. John Grohol is not entering into a professional therapeutic relationship with you; this consultation is not a substitute for nor should it be used instead of a relationship with a mental health professional. By pressing the Yes, I agree button below, you hereby express your understanding and acceptance of the above Important Notice, as well as the general terms of use, and to pay the fee associated with the service level you have choosen. No, abandon this form

Last reviewed: By John M. Grohol, Psy.D. on 30 Dec 2003