I have designed some questions that will help me help you. However, you certainly don’t have to answer any questions you don’t want to. This form is designed to save you some expense and time by covering some basics before we have our first conversation.  Feel free to use it as you see best.

Please Describe The Topic You Desire Professional Advice For (You Will Have An Opportunity To Explain In Further Detail At The Time Of Your Appointment):

Have You Survived Any Sexual Abuse Such As Incest, Molestation Or Rape? Yes No

If So, Have You Participated In Professional Counseling/Treatment Or 12 Step Support Groups Specific To The Abuse? Yes No

Childhood Religious/Spiritual Background Athiest Agnostic Protestant Catholic Jewish Islamic Buddhist Hindu 12 Step None Other

Current Religious/Spiritual Background Athiest Agnostic Protestant Catholic Jewish Islamic Buddhist Hindu 12 Step None Other

Sexual Preference Bisexual Straight Gay Lesbian Fluid Other

Biological Gender (What Type Of Anatomy Do You Have?) Female Male Transexual Intersexed Other

                

Name Email Confirm Email Phone Number Alternate Number Best Time To Call ** **