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Psychological Questionare

 

 

Name:
 
Age and gender:
 
Country and state:
 
Marriage status:
 
Occupation:
 
E-Mail Address:
 

Please describe your current living situation:

 

 

Religion:

(all denominations will treated)*

Note: if you have converted to Judaism please write what kind of conversion, i.e.: orthodox, reform. And that you have converted.

 
Is your mother Jewish? Did she convert if so please state so below.
Yes No
 
Are your grandmothers Jewish? If only one please explain in.
Yes No
If answered yes Please describe
 
Is your father Jewish
Yes No
 

a. Are you currently in, or have
you ever been in, psychiatric
treatment or therapy?
If so, please describe:

b.Have you ever required psychiatric hospitalization? Please describe

a Yes No

b Yes No

 
Do you currently use, or do you
have a history of using, drugs or
alcohol?  If so, please describe:
Yes No
If answered yes Please describe
 

Have you ever taken or are you currently taking any psychotropic medication (antidepressant, mood stabilizer, sleep medicine, antipsychotic,etc.)

Please list.

 

What do you want to see different as a result of e-therapy?:

 
Are you willing to do extra work on your own time? Such as reading articals or pratical exercises?
Yes No
 
Do you have any medical problems? Please list them, including all medications prescribed for any condition.
 
Have you recently had significant change in your sleep pattern or significant weight loss or gain?
Yes No
If answered yes Please describe
 
Are you experiencing, or have you ever experienced hallucinations (heard or saw
things that weren't there), delusions (believed something was happening that
wasn't), or paranoia (thought someone was after you when no one was)?
Have you ever been diagnosed with schizophrenia or paranoia?
Yes No
If answered yes Please describe
 
Have you ever felt suicidal, tried to commit suicide or tried to hurt yourself or someone else?
Yes No
If answered yes Please describe
 
Do you have any thoughts of doing harm to others? Have you ever physically hurt anyone?
Yes No
If answered yes Please describe
 

Tell me what kind of issues would you like to talk about?

Also, tell me a little about background and your yourself.

 
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