Sexual Orientation Resolution
Therapy Questionnaire

If you are considering counseling with Dr. Consiglio read Making a Counseling Appointment, then please fill out this questionnaire and press "SEND" below. Remember Romans 8:28 "All things are working together for your good if you love God and are called according to His purposes."

*Please answer the following questions:*
1. Are you married or single?
2. Is your problem with homosexuality mostly internal or behavioral? Explain briefly.
3. How have you been feeling lately? Dominant feelings?
4. What do you think has made you seek counseling right now? Is there some crisis?
5. Have you had any prior psychotherapy/counseling? If so, when?
6. Are you currently on any medications? If so, please list and include dosages, if known.
7. Are you allergic to any medications? If so, which ones?
8. Do you have a family history of mental illness of 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 ben 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:
15. Have you ever been treated for substance abuse or addiction? If so, when?
16. Do you have any current or past major medical problems? Please describe very briefly.
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 going to a therapist?

From the following table, check the box in front of any of the items that you feel apply to you:

1.Headaches	2. Naive	3. Memory problem
4. Heart palpitations	5. Nervous	6. Unattractive
7. Sleep problems	8. Cowardly	9. Bored
10. Want to hurt self	11. Timid	12. Restless
13. Drug problems	14. Can't concentrate	15. Nightmares
16. Financial problems	17. Worthwhile	18. Life is empty
19. Incompetent	20. Regretful	21. Fatigue
22. Pushy	23. Misunderstood	24. Tense feeling
25. Shy	26. Sympathetic	27. Sex problems
28. Don't take vacations	29. Intelligent	30. Worthless
31. Confused	32. Fainting spells	33. Stupid
34. Considerate	35. No appetite	36. Evil
37. Deformed	38. Alcohol problems	39. Overambitious
40. Read my Bible	41. Go to church	42. Trusting God
43. Not confident	44. Depressed	45. Good person
46. Can't make decisions	47. Inadequate	48. Dizziness
49. Can't make friends	50. Horrible thoughts	51. Attractive
52. Stomach trouble	53. Guilty	54. Lonely
55. Panicky feeligs	56. Hateful	57. Unloved
58. God is absent	59.Can't Pray	60. Loss of faith
61. Shaking	62. Inferiority feelings	63. Confident
64. Unable to relax	65. Home conditions bad	66. Can't keep a job

Use this space to add any other words, thoughts, feelings that apply to you:

Please fill in the following information:

Items with a * are Required information!

*Your Full Name:

*Date of birth:

Address Line 1:(street address)

Address Line 2:(city, state/province, zip/postal code)

Address Line 3:(country / other)

Home Telephone Number:

Work Telephone Number:(optional)

*Email Address:

Social Security Number:

Name of insurance:

Who referred you to Dr.Consiglio?

*What is your preferred method of counseling? In-Person Office Counseling
Phone TeleCounseling
Internet E-mail Counseling

FREE feedback form powered by Freedback.com

Items with a * are Required information!
*Your Full Name:
*Date of birth:
Address Line 1:(street address)
Address Line 2:(city, state/province, zip/postal code)
Address Line 3:(country / other)
Home Telephone Number:
Work Telephone Number:(optional)
*Email Address:
Social Security Number:
Name of insurance:
Who referred you to Dr.Consiglio?
*What is your preferred method of counseling?	In-Person Office Counseling Phone TeleCounseling Internet E-mail Counseling