TO BEGIN, TELL MARTI A LITTLE ABOUT YOURSELF

Note ~ You must be 18 years of age or older to take part in counselling services offered by Marti Steenwyk, unless parental consent has been issued.
Name:    
Phone:    
Sex: Age:
Occupation:    
Marital Status:    
Education (grade completed or degree):    
Special Training:    

General Physical Health:

    
     
Describe any serious illness or accident    
Recent weight change:
Yes: No:
Date of last Physical Examination:    
Are you now taking medication?:
Yes: No:
If so, for what and what kind      
 
Have you ever had counselling or psychotherapy before:
Yes: No:
   
Have you ever had a severe emotional upset?:
Yes: No:
   
If yes, please explain      
Have you recently experienced the loss of someone close to you?:
Yes: No:
   
If yes, please explain      
Have you recently experienced social, business or other loss:
Yes: No:
If yes, please explain