Date:

Please write all answers legibly. Should you not have enough room to complete an answer, continue the answer on the back of the page (please indicate the number of the question you are continuing).

1) What are the primary reasons for your seeking treatment?

2) Briefly describe the history and development of your reasons for seeking treatment (from onset to present). How have your issues impacted your life?

3) What goals do you want to accomplish through therapy?