.
 . .
.
CONFIDENTIAL
QUESTIONNAIRE
tslife.com

All information provided is confidential

 .
.

    Name



    Address


. City State

Zip

Years lived here

    Who else lives with you?
    Relationship and Ages.


. Phone Fax

E-mail

    Birth date
(MM/DD/YR)
    Citizenship


    Social Security Number


    If Transsexual
Male to Female

Female to Male


Or list relationship to a transsexual?
    Marital History
Please list: Single, Married, Divorced, Partner Deceased




Name of husband or wife and marital date




Children List
(Parents Names and Child’s Sex and Birth date)
    Last Year of School or College Completed


    Current Employer


Your Title

Years employed here

    Former Employer


Your Title

Years employed here

    Former Therapy


    Name and Profession of Therapist


Years in Therapy

Was it helpful?

    YES

    NO

    List any problems with the law within the last five years with place and date




    List any physical or mental health problems within the last five years. Include drug or alcohol problems.




    How and when would you like to be contacted?



.
.



.
.



.