Background Questionnaire for Adults
Name *
Your answer
Today's Date *
Your answer
Street Address, City and Zip Code *
Your answer
Telephone *
Your answer
Gender *
Date of Birth *
Your answer
What is your primary reasons for seeking therapy?
Your answer
When you feel bad, what is the feeling you most often have?
Your answer
Have you tried to get help previously? If so, what kind, with whom, and when?
Your answer
What aches, pains or physical discomforts do you have?
Your answer
Have you been hospitalized in the past? For what?
Your answer
What serious illnesses and accidents have you had in the past?
Your answer
How often do you drink and how much?
Your answer
What drugs have you used and for what?
Your answer
Who referred you?
Your answer
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