Thank you for taking the time to answer these questions before our upcoming appointment. Your responses will provide important information to help us understand the issues and problems that you are facing.

Please be as complete and accurate as possible in answering these questions - but do not worry if you have difficulty with specific questions or details. We can discuss your responses in more detail during our appointment.

Finally, please note that any information you provide on this form could be included in the final report resulting from your assessment.