Personal Information

    Name:
    Surname:
    Sex:
    Sexual Orientation:
    Age:(Minimum age is 18)
    civil State:
    Your E-mail:
    Phone:
    Mobile:
    Education Level:



    Emergency Contact

    Name, Phone, E-Mail and type of relationship (spouse, son, mother, etc.) of someone to contact in case of emergency:



    Questionnaire



    Remember that all information is protected in our terms and conditions


    1. Housing. With whom you live? (Only accompanied, if with family, with whom (s) - own house, rented, etc.) how satisfied you are with your housing situation?
    2. What is your job? Do you currently have a job? How satisfied (or not) you are in your work? Please describe a typical day of work or activities if you do not work.
    3. What is the reason for seeking psychotherapy at this time? What is the problem you want to explore? Please use all the space you require and as explicit as possible.
    4. Do you have some specific symptom(s) (p. Eg. Depression, fatigue, anxiety, lack of energy, irritability, lack of motivation, mood changes, etc.) or you have been diagnosed with a condition or mental disorder? Please be as specific as possible.
    5. What is your current stress level? What stresses you out? How can you deal with stress? (Includes healthy ways and not so much to do).
    6. Can you tell me about your eating habits? Do you eat well? Do you have or have you had an eating disorder (anorexia, bulimia, binge eating, extreme loss of appetite)?
    7. Do you sleep well or suffer from insomnia or hypersomnia? Do you dream about? ¿Recurring dreams or nightmares? Dreams are a valuable tool in psychotherapy, do not hesitate to include them in our work.
    8. Do you think or have you recently thought about suicide, to hurt someone or do you have behaviors that others would consider extreme or hazardous (cut off, putting yourself unnecessarily at risk, etc.)? Please explain it in detail.
    9. Have you ever been in therapy? How long? How would you describe your experience? Tell me about what happened in your therapy, what helped or did not help? Why did it end? also include if you have consulted with a psychiatrist or take some kind of psychiatric medication (if so, include the drug name, dose, why did you take it and, in your opinion, tell me if taking it helps you).
    10. Tell me about your history with the use of alcohol and / or drugs, including cigarettes, coffee, drugs, etc. It includes information you think might be useful to us. For example, if you take alcohol, since when? How much and how often? Do you think causes you problems? Someone close to you thinks that your consumption is problematic? Same request for other legal or illegal substances. Do not forget to include whether your use of any substance has caused you legal problems.
    11. Tell me about your family of origin. With whom did you grow up? What can you tell me about your relationship (in your childhood and currently) with your parents? ¿Divorces, deaths, violence, abuse, etc.? Siblings and sisters, how many and how it was / is your relationship? What place you occupy in the family? Tell me, perhaps using images or metaphors how was your childhood?
    12. Tell me about your romantic relationships (including but not limited to your current relationship if you are in one). Have you noticed similarities between your relationships? (The kind of partner that attracts you, -level aspects of sexual activity, satisfaction, etc., type of problems they have, like fighting or end relationships, etc.). if there is history also it includes divorce (s), violence, infidelity, etc., that you think can be relevant.
    13. Tell me about your spiritual or religious life. What religion did you grow up? Do you practice any form of spirituality? Do you consider yourself someone spiritual? (Whether or not be so attached to a specific religion) Is it important in your life?
    14. What are your fears or fantasies about what might happen in therapy?
    15. What do you expect to get from therapy? What would you consider a successful outcome of our work together?
    16. Do you want to add something else that you think it would be good to know to help?
    17. How urgent is your need for therapy? (The sessions are scheduled based on availability, but depending on the urgency do their best to accommodate my schedule to your needs) HighMediumLow
    18. We're done! I know that answering these questionnaires can be difficult and even activate certain memories or painful feelings. Thank you very much for your courage and honesty. If you allow me one last question: How do you feel and / or what was going through your mind while you were answering this?

    By Clicking and sending the information, Hereby I declare that I have read, understood and accepted the Terms and Conditions governing the therapeutic relationship between Sergio Rodriguez Castillo and Me.
    Your full name:
    Date:



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