A CURE FOR ART - PRE-TREATMENT QUESTIONAIRE

 
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PERSONAL DETAILS

Name

Date of Birth

Male Female Other

Contact e-mail


Area of Cultural Practice

Preferred Language

Physical Appearance

Cultural or Spiritual Needs

Physical Abilities and Needs


Circumstances Surrounding your Need for a Cure


CLINICAL SYMPTOMS

Anxiety/Fears (if you have any) are they about:

describe them in detail

Depressive Symptoms

I find my symptoms:

interesting
potential subject matter

just depressing

Sleep

only when chemically aided
as much as possible
fitful, plagued by horrid dreams

Eating

never have time
borderline eating disorder
too much
only when someone else pays

 

Problem behaviour

Psychotic features

Relationship Problems

Developmental History/Problems

Alcohol/Drug abuse

Attitude towards Society