Questionnaire
 

 For Counseling Clients Only

Please respond to all questions that you feel comfortable answering. All information on this questionnaire will be kept confidential.
(* Required)

Name
Email *
Confirm Email *
Gender Male      Female
Age
Marital Status
Do you have
children?		 Yes      No

 
If Yes, please list them with names and ages, and include any non-biological children who live (full or part time) in your home (stepchildren, foster children, etc.).
 
Occupation

 
Employment
Status
 
 
Please briefly describe the problem(s) that you are having:

 
How severe would you rate your symptoms?  
 
Are you currently seeing a mental health professional?
Yes      No
 
Have you been treated by a mental health professional in the past?
Yes      No
 
If Yes, for what reason?
 
What was the outcome of this experience?

How would you rate your overall physical health?

 
Do you have any medical problems that you think may be contributing to your present problems or circumstances?

 
Please use the space below to enter any other information that you feel is important for me to have:

     


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© 2006 Sara Lapides