FIELDS MARKED WITH * ARE REQUIRED!


 Your Name:*          

 City:*               
 
 State:*              

 E-Mail Address:*     

 Marital Status:      Single
                      Married
                      Divorced
                      Widow
                      Widower
                      Remarried


 Male Children:       

 Female Children:     

 Their Ages:          

 First Time with a    Yes
 Councelor?: 	      No

					   
 If Not How Long?:     Yrs
 
                       Months

 
 Briefly describe this experience:
		      
 
 
 Alcoholism History:  Self
                      Mother
		      Father
		      Sister
		      Brother
		      Son
		      Daughter
					  
 Drug Abuse History:  Self
                      Mother
		      Father
		      Sister
		      Brother
		      Son
		      Daughter

 Mental Illness:      Self
                      Mother
		      Father
		      Sister
		      Brother
		      Son
		      Daughter

 How vested are you in making changes in your life
 that will help you obtain Positive Outcomes?:
		      Extremely
		      Very
		      Moderate
		      Not Very
				  

 Has your concern, issue or problem caused
 you to miss  work or school?: 
		      Yes
		      No

 If So, How Long?:     Days in the last month
		       Days in the last 3 months 
		       Days in the last 6 months 
		       Days in the last Year
 

 When did the issue/concern you are emailing about start?
		      


 What results do you hope to achieve by
 participating in speaking with Me?:
		      

 When done, please  or