NAME *

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DATE *

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DD

YYYY

ADDRESS *

Address 1

Address 2

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MARITAL STATUS *

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PLEASE CHECK ALL OF THE ISSUES OR FEELINGS YOU ARE PRESENTLY EXPERIENCING OR WITH WHICH YOU HAVE RECENTLY STRUGGLED *

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DEPRESSION

ANXIETY / FEAR

ANGER

GUILT / SHAME

LOW SELF-ESTEEM / LACK OF CONFIDENCE

PERFECTIONISM OR OBSESSIVE BEHAVIOR

SUBSTANCE ABUSE (ALCOHOL, DRUGS, ETC)

EATING DISORDER OR WEIGHT PROBLEMS (ANOREXIA, BULLIMIA, BINGE EATING, OVEREATING)

ADDICTIONS (OTHER THAN THOSE LISTED ABOVE (I.E. GAMBLING, SMOKING, SEX, WORK)

PROBLEMS OBTAINING OR KEEPING A JOB

RELATIONSHIP PROBLEMS (MARRIAGE, DATING, FAMILY, FRIENDS)

SPOUSAL ABUSE / VIOLENCE