In order to help you have the most satisfactory experience choosing a therapist I need you to answer some questions. If you are unsure about any question, you can leave the answer blank. These questions are designed to help you focus on the issues that might be troubling you. These questions are not designed to diagnose, rather they are designed to help you get started in identifying you needs in therapy.

Everyone seeking therapy has a cluster of difficulties that cause them to come for help. These tend to fall into a few categories. Please answer the following questions to the best of you ability. It does not matter if the answers are exactly correct as long as they reflect your current experience.

Your Current Concerns:

1. Are you having trouble with difficult feelings such as sadness, loss of interest in life, low energy -etc.?
   
   
2. Do your moods and energy fluctuate greatly from highs to lows?
   
   
3. Do you experience periods of extreme irritability and anger.
   
   
4. Are you troubled by fears and anxiety? If so, is the fear about some particular thing or situation? (flying, social situations, animals, safety, etc.)
   
   
5. Do you feel impulses or compulsions to perform behaviors or actions that you know are harmful to you? (over or under eating, drinking, drug-taking, smoking, promiscuous sex, etc.)
   
   
6. Are you currently having problems with your intimate relationship/s?
   
   
7. Are you having conflict or difficulties in your family?
   
   
8. Do you have physical problems that you believe are made worse by stress or your state of mind?
   
   
9. Are you coping with particularly difficult changes or transitions in your life? (losses of people or activities, aging, divorce, etc.)
   
   
10. Have you experienced traumatic events or incidents in your life that you feel are still affecting you? (sexual abuse, rape, violence, etc.)
    
    
11. Do you experience other problems that are not mentioned here?

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