| Questionnaire |
Please fill out the following questionnaire. At the end there is space to tell me as much as you like about the issue you would like advice about.
If you are unsure about filling out this form, or you would like to know why I am asking for so much information, go to the Help page and read the Help Asking For Advice section.
Before filling out the questionnaire, a reminder: you must be over 18, not suicidal and you must have read the legal & privacy agreements. Please do not submit the questionnaire if you do not meet these criteria. |
| Initials or Pen Name: |
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| E-Mail Address: |
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| Age: |
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| Sex: |
Male
Female |
| Marital Status: |
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| Location: |
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| Have you ever been in any form of counselling, coaching or psychiatric treatment? |
Yes
No
If so, please describe:
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| Any medical problems? |
Yes
No
If so, please describe:
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| Any current or past psychiatric medications (e.g antidepressants, sleep aids)? |
Yes
No
If so, please list:
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| What role do alcohol and other drugs have in your life? |
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| Who do you usually turn to for advice? What, if anything, have they said about your current problem? |
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| What is the problem you would like my advice about? |
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Wordsbykim may publish my letter in the advice column of the site.
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Do you wish me to contact you via email with my response?
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