|
|
|
|
Confidential Questionnaire
When you are seen for an interview by one of our psychotherapists you will have the opportunity to talk about your difficulties and why you wish to apply for therapy. We have however found that it is useful to have some preliminary information and we ask you to provide this by filling in this form and returning it to us by Fax or by Post should you wish to apply for an interview.
NAME : ADDRESS :
TELEPHONE :
DATE : AGE : DATE OF BIRTH : MAY WE HAVE THE NAME AND ADDRESS OF YOUR GP?:
WHO SUGGESTED THE LONDON ASSOCIATION OF PRIMAL PSYCHOTHERAPISTS TO YOU ?
1. PLEASE DESCRIBE THE NATURE OF YOUR DIFFICULTIES AS YOU SEE THEM. HOW LONG HAVE YOU HAD THEM ? HOW ARE YOU AT PRESENT ? HOW HAVE YOU BEEN AT YOUR WORST ?
2. WHAT ASPECTS OF YOUR LIFE GIVE YOU SATISFACTION ?
3. IN WHAT WAY DO YOU HOPE THAT PRIMAL PSYCHOTHERAPY WILL WORK FOR YOU ?
4. HAVE YOU HAD ANY PREVIOUS PSYCHIATRIC TREATMENT ?
5. HAS ANYONE IN YOUR FAMILY HAD ANY PSYCHIATRIC TREATMENT ?
6. HAVE YOU HAD ANY PREVIOUS PSYCHOTHERAPY ? IF SO, PLEASE GIVE DETAILS.
7. PLEASE COMMENT ON YOUR PHYSICAL HEALTH . HAVE YOU HAD ANY SERIOUS ILLNESSES OR OPERATIONS ?
8. HAVE YOU EVER MADE A SUICIDE ATTEMPT ? IF SO, PLEASE OUTLINE THE CIRCUMSTANCES.
9. ARE YOU TAKING ANY MEDICINES AT THE MOMENT ?
10. ARE YOU TAKING OR HAVE YOU EVER TAKEN ANY NON-PRESCRIBED DRUGS ? IS THERE ANY CONCERN ABOUT YOUR DRINKING ? IF SO PLEASE GIVE DETAILS OF AMOUNT OF ALCOHOL CONSUMED AND FREQUENCY ? DO YOU SMOKE ? IF SO HOW MANY ?
11. PLEASE GIVE US DETAILS OF YOUR FAMILY.
12. PLEASE TELL US SOMETHING ABOUT YOUR MOTHER, HER PERSONALITY AND YOUR RELATIONSHIP WITH HER.
13. PLEASE TELL US SOMETHING ABOUT YOUR FATHER, HIS PERSONALITY AND YOUR RELATIONSHIP WITH HIM.
14. PLEASE LIST YOUR BROTHERS AND SISTERS ( INCLUDING HALF BROTHERS AND SISTERS AND STEP-BROTHERS AND SISTERS).
14B. WERE THERE ANY ABORTIONS, MISCARRIAGES OR STILLBIRTHS THAT YOU KNOW OF ?
15. COULD YOU TELL US SOMETHING ABOUT YOUR CHILDHOOD ? WHAT CHANGES WERE THERE ? WERE THERE ANY IMPORTANT RELATIONSHIPS ( EG. WITH GRANDPARENT, AUNTS AND UNCLES, NANNIES, CHILDMINDERS, FRIENDS.)
16. DO YOU HAVE ANY INFORMATION ABOUT YOUR BIRTH ? EG. CAESAREAN, FORCEPS.
17. ARE SINGLE/LIVING WITH A PARENT/MARRIED/SEPARATED/DIVORCED/WIDOWED ?
18. IF YOU ARE OR HAVE BEEN MARRIED OR LIVING WITH SOMEON, PLEASE STATE
FOR HOW LONG: AGE OF HUSBAND/WIFE/PARTNER: HIS/HER OCCUPATION:
19. PLEASE TELL US SOMETHING ABOUT YOUR PARTNER:
20. DO YOU HAVE ANY PROBLEMS OR UNHAPPINESS IN YOUR PARTNERSHIP OR FAMILY LIFE ? IF SO PLEASE DESCRIBE THIS. WHAT ASPECTS OF YOUR RELATIONSHIP ARE GOOD FOR YOU ?
21. DO YOU HAVE ANY SEXUAL PROBLEMS?
22. PLEASE LIST YOUR CHILDREN, INCLUDING STEP-CHILDREN. PLEASE ALSO INDICATE ANY STILLBIRTHS, MISCARRIAGES OR ABORTIONS.
23. PLEASE TELL US SOMETHING ABOUT YOUR CHILDREN .
24. PLEASE TELL US ABOUT YOUR SCHOOLING AND ANY FURTHER EDUCATION. WHAT KIND OF EXPERIENCE WAS IT ?
25. WHAT IS YOUR PRESENT EMPLOYMENT ?
WHAT ARE YOUR PLANS AND PROSPECTS IN YOUR WORK ?
WHAT DO YOU ENJOY ABOUT YOUR WORK AND WHAT FRUSTRATES YOU ?
26. IF YOU WERE ACCEPTED INTO THERAPY, HOW WOULD YOU FINANCE YOUE THERAPY AND WHEN WOULD YOU BE AVAILABLE FOR SESSIONS ?
27. PLEASE TELL US ANYTHING ELSE YOU THINK WOULD BE IMPORTANT OR USEFUL FOR US TO KNOW.
|
|
Send mail to [email protected] with
questions or comments about this web site.
|