APPLICATION

Name:
Date:
  
Email Address:
Tel. No.
  
Date of Birth:
Education:
  
Ages of Children:
Occupation:
  
SS#
Marital Status:
Height and Weight:

All information provided will be held in strict confidence.

1. Previous Outpatient Psychiatric Treatment?
Yes
No
Dates and Duration:
Diagnosis:
Type of Therapy:

2. Previous Psychiatric Hospitalizations?
Yes
No
Dates and Duration of Stay:

3. Please Describe Any Extreme Disability Since Age 18; Including Dependence on Friend, Family, or Government:
   
4. Suicide Attempts?
Yes
No
Circumstances and Dates:
5. Please Describe Your Employment History; Including the Type and Duration of Jobs:
   
6. Have You Ever Been Arrested, Indicted, or Convicted of a Crime?
Yes
No
    Please Describe the Circumstances:
   
7. Medical History - Do You Suffer From:












 
8. Please List Any Current or Past Prescription Medications You Have Taken:
   
9. Emotional Disorders - Do You Suffer From:












 
10. Please Describe Any Sexual Dysfunctions, Sexual Identity Conflicts, or Sexual Perversions:
   
11. Please Describe Any Current or Past Drug or Alcohol Use:
   
12. Please Describe Any Other Addictive Behaviors Including Use of Cigarettes, Caffeine, and Food:
   
13. Please Describe Any Significant Circumstances of Your Birth or Early Care:
   
14. Please List the Sex and Ages of Your Siblings:
   
15. How Do You Plan to Finance the Intensive Phase of Therapy and Subsequent Follow-Up?
   
16. Please List the Month and Year You Would Prefer to Start Therapy:
   

 

 

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The Primal Institute
10379 Pico Boulevard
Los Angeles, CA 90064

TEL: (310) 785-9456
janov@primalinstitute.com