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1. Have you previously undertaken therapy or received psychiatric care

2. Have you ever been prescribed psychotropic medication for a psychiatric condition

3. Have you ever been admitted to a Psychiatric Hospital

4. Do you have any medical problems - If so please list with medication.

5. Have you recently had changes in your sleep pattern, weitght loss or gain.

6. Have you ever been dignosaes a schizophrenia or paranoia -

7. Do you have thoughts of suicide - Do you have thought of harming yourself

8. Do you have thoughts of harming others - Have you ever physically hurt anyone

9. Explain what brings you to therpay - What type of therapy would you

10. Tell me about yourself

I have read and agree to the General Disclaimer

I have read and agree to the Privacy - Statement

If Yes - please describe