This Questionnaire is for the participant who has enrolled in the AW Program beginning with Learning 2, not for the first month participant. Answer the following questions and issues as truthfully as you can! You can copy the questions into an email and send it that way (wconsiglio2@comcast.net), or (allthings@counsellor.com), or, if you like you can send it by post to the following address: Dr Bill Consiglio, 876 Shepard Ave, Hamden CT 06514, USA.

Please answer the following information:

PART I * Required!
*Your Full Name:
*Date of birth:
Address Line 1:(street address) (optional)
Address Line 2:(city, state/province, zip/postal code) (optional)
Address Line 3:(country / other)
Home Telephone Number: (optional)
Work Telephone Number:(optional)
*Email Address:
*Do you consider yourself a Born-Again Christian? How long?
*Do you attend or minister at church regularly?
*What denomination?

PART IIAnswer All!
1. Are you married or single?
2. Is your problem with sexuality mostly internal (eg thoughts) or behavioral?
3. How have you been feeling lately? Dominant feelings?
4. What do you think has made you seek help right now? Is there some crisis?
5. Have you had any psychotherapy/counseling? If so, when?
6. Are you currently on any medications? If so, please list and include dosages, if known.
7. What is the medication for?
8. Do you have a family history of mental illness or substance abuse?
9. Have you ever attempted suicide, or had a plan to hurt yourself you never carried out?
10. Do you currently have any thoughts or feelings of wanting to physically harm yourself? If so, do you also have a specific, concrete plan to do so?
11. Have you ever been diagnosed with an eating disorder (anorexia/bulimia)?
12. Were you physically abused as a child?
13. Were you sexually abused as a child, or do you suspect that you might have been?
14. Describe your current usage of alcohol and/or drugs: low, moderate, high?
15. Have you ever been treated for substance abuse addiction? If so, when?
16. Do you have any current or past major medical problems? What?.
17. Do you have (1) current sleep difficulties, or (2) decrease/increase in appetite?
18. What would you like to see happen as a result of this Program?
19. Have you ever been arrested or convicted of an illegal activity?
20. Have you been involved in any form of child (under age 18) pornography or sexual activity?

PART III

From the following list, copy or print these, then circle or mark the items that you feel apply to you:

Headaches Cowardly Bored Nightmares Pushy Misunderstood Financial problems Don't take vacations Intelligent Nervous Anxious feelings Hateful Unloved Can't pray Loss of faith

Naive Unattractive Sleep problems Want to hurt myself Timid Restless Drug problems Can't concentrate Worthwhile Empty life Horrible thoughts Attractive Stomach trouble Lonely

Memory problem Regretful Incompetent Fatique a lot Tense Shy Sympathetic Sex problems Confused Fainting spells Inadequate Dizziness Medical Problems Can't make friends Can't relax

Heart palpitations Stupid Considerate No appetite Evil Alcohol problem Overambitious Good Christian Go to church Read my Bible Not confident Depressed Indecisive Trust God Home conditions bad

PART IV

Use this space to add anything else you would like to share which would help me know you better: