Thank you for taking the time to complete and return this questionnaire. Your responses will help us know you better and work with you more effectively.

    Please use one word ONLY to describe:

    In ONE sentence, please describe:

    Please list all members of your FAMILY OF ORIGIN - including parents, stepparents, sisters and brothers, and any others who lived with you growing up. Also include any very significant person (like a grandparent, aunt, or uncle) who had a major impact on your life:

    Any significant person (like a grandparent, aunt, or uncle):

    Why did you decide to start therapy at this particular point in time?

    What will be different in your life when you complete therapy?

    Please indicate any current medical problems and prescribed medications:

    Please list dates of all prior experiences with therapy/counseling, psychiatrists, psychiatric hospitalization, and/or residential rehab:

    Please indicate current use of alcohol or other drugs, and any treatment or 12-step program experience:

    What I like the most about my life right now is:

    These days I am mostly feeling (select one or two):

    This is how I cope with stress in my life:

    This is how I avoid dealing with problems in my life:

    What I want to ask my therapist is:

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