Client Questionnaire

Please fill out the form below

You do not have to answer any questions that you are uncomfortable with.

Sex

On vacation, do you prefer relaxation or excitement?

Are you being treated by a physician?

Are you being treated by a psychologist/psychiatrist/social worker?

Are you currently experiences any of the following ( please check all that apply)

Are you currently experiences any of the following

I Agree

1 + 9 =

CLIENTS MUST NOT OPERATE A MOTOR VEHICLE OR PERFORM ANY TASKS THAT REQUIRE COMPLETE ATTENTION

AND CONCENTRATION FOR AT LEAST 30 MINUTES AFTER THE END OF THE SESSION.