The purpose of this questionnaire is to obtain a comprehensive picture of your background. By completing this questionnaire as fully and as accurately as you can, you will provide your therapist with important information, without having to use your actual therapy session minutes. The information is this questionnaire will be kept by your therapist. As with all confidential information, all patient records are kept under strict confidence and will not be disclosed to anyone without your written permission. If you feel that you do not wish to answer a question, simply write, "Do not care to answer." If you wish to provide additional information, please use the last page, thank you.
***THIS FORM TAKES APPROXIMATELY 20 MINUTES TO COMPLETE