General Information Questionnaire General information questionnaire Name First Last Email(Required) GenderMaleFemaleOtherAgeRelationship StatusMarriedIn a Long-Term RelationshipSeparatedDivorcedSingleOtherPlease answer as you are comfortable, briefly or at-length. If you would prefer to write up in a Word doc or email and send to me, please feel free to do that. I will read it.Describe your history of sexual compulsive behaviorDescribe the events that have led you most recently to seek treatmentDescribe your childhood and relationship with your mother, father, and siblingsDescribe your current relationship and family including childrenDescribe any previous therapy or treatment approachesPlease list medications you are currently takingPlease tell me anything else you'd like me to knowReview and uncheck if not applicable I am a current or possible future client of Karuna Healing Recovery Coaching and Therapy Services and consent to allow my therapist or coach to view my report in order to analyze and discuss the results with me.
