2. What types of psychotherapy or counseling have you done previously, and for how long? *
Your answer
3. What were your primary reasons for seeking therapy, and what were the major issues addressed? *
Your answer
4. Are you on any medications? If so, what are they, and what are they for? *
Your answer
5. Have you been on prescription medications for psychological/emotional challenges? *
Your answer
6. Have you ever been hospitalized for psychological/emotional disorders? *
Your answer
7. Have you ever experienced a bad drug trip, and if so, what happened? *
Your answer
8. Do you use tobacco, caffeine, drugs, and/or alcohol? If so, how much and how often? *
Your answer
9. Have you ever had an addiction to substances, porn, sex, eating, etc.? If so, how did you work with this, and how long has it been since any active addiction? *
Your answer
10. What was your religious upbringing? *
Your answer
11. Current spiritual practice? *
Your answer
12. Are you affiliated with a particular group or religious organization? *
Your answer
13. What were the major challenges in your family dynamics as a child? (Please write at least a few paragraphs about this.) *
Your answer
14. What have the major challenges been for you as an adult? (Please write a few paragraphs about this.) *
Your answer
15. Have you experienced any type of abuse? If so, please describe. *
Your answer
16. Have you ever been convicted of a crime? If yes, please describe. *
Your answer
17. Have you ever attempted suicide? If yes, please describe. *
Your answer
18. Any significant accidents/injuries/illnesses? If yes, please describe. *
Your answer
19. Any military service? If yes, please describe. *
Your answer
20. Are you currently in an intimate relationship? If yes, for how long? Is it committed? Monogamous? Any affairs? *
Your answer
21. If not currently in relationship, how long since your last one? *
Your answer
22. What have been your major challenges throughout your history of intimate relationships? (Please write at least a few paragraphs about this. You don’t need to list all your past relationships, but rather the psychological/emotional challenges in the main ones.) *
Your answer
23. What main things would you like to address in your work with Teena? What are you hoping will happen as a result? (Please write at least a few paragraphs about this.) *
Your answer
24. What haven't I asked about that would be important for me to know about you? *
Your answer
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