Childhood Access Questionnaire for Self-Therapy Journey

Self-Therapy Journey
Childhood Access Questionnaire
This questionnaire is to help me decide if accessing the childhood origins of your patterns in Stage 2 of Self-Therapy Journey is appropriate for you. After you fill it out and I look at it, then I will interview you.

Jay Earley, PhD
Please enter your name*

First NameLast Name
Plese enter your E-mail address*
What psychological issues are you facing now or wanting to work on?*
How much and how frequently do you currently use drugs and alcohol?*
What therapy or personal growth work have you done?
What kind of work have you done on exploring the childhood origins of your psychological issues? Has it been difficult for you emotionally?
Do you a history of trauma or abuse? Please explain.
Do you have any history of emotional instability? Please explain.*
Is there any danger that accessing painful or traumatic childhood memories could be destabilizing for you?*
Have you been hospitalized for psychiatric reasons or treated with psychiatric drugs? Are you currently on any psychiatric drugs?*
Are you currently in psychotherapy or counseling? For how long?*
If you were in emotional difficulty or felt like you were falling apart, where would you turn?*
Should be Empty: