This questionnaire will provide important information to assist us in our work together. Often it can be helpful to gather as much information as possible in order to get a full picture of a problem. It is for this reason that the following questions cover a broad range of topics.

There are quite a few questions in this questionnaire; however, by completing it you will provide me with a comprehensive overview of your life. This will provide information in order to fully assess your situation. Because it is in writing it will provide information both now and, as needed, in the future. Also, by going through the process of answering these questions, you may find that it helps to understand and clarify the nature and extent of your difficulties.

Feel free to skip any questions that you do not feel comfortable answering. Required questions are 


Name *
Date of Birth *
Date of Birth
Were you adopted? *
Check any of the following that applied during your childhood

Thank you so much for taking the time to help me get to know you a bit better!