Voice: (205) 329-7815, fax: 329-7816
Richard Azrin, Ph.D. Cheryl Millsaps, Ph.D.
Instructions: Please complete this form as accurately and completely as you can. Dr. Azrin will discuss your responses with you.
DONT HIT THE BACK BUTTON OR YOU WILL LOSE EVERYTHING.
Scroll up or down to correct answers.
Activities of Daily Living:
Alcohol or Substance Use:
Please describe below if you have ever had any treatment for psychiatric/psychological difficulties
Family Medical History
Please list your past jobs, even if not presently working.
If you don't see the green check box saying "Thank you"
after you hit Submit, then your form did not submit properly
If you don't see that Thank you, then please submit again or try saving, or you may have to do the form over again