Either complete the Personal Questionnaire using the following online form, or download and print the attached Word or PDF documents and submit them to Emory by email, snail mail, or in person.

Download Personal Questionnaire

Online Personal Questionnaire

Thank you for taking the time to answer these questions.  Your answers save us valuable session time and improve my ability to be helpful to you. I assure you that brief answers are fine, but longer answers are also useful if you wish to provide more detail.

Your Name: (required)

Your Email: (required)

  1. What would you say are your most positive characteristics and abilities?

  2. Would you say these positive qualities and abilities help you function better and deal with the challenges you face, whatever they may be?

  3. What would you say are the main challenges you are facing at present?

  4. What is the most important problem you would like my help with?

  5. If you were to give this problem a name or describe it with a phrase, what would that be?

  6. Is this a new problem or has it been around for a while?

  7. What effect does this problem have upon you?

  8. What bothers you the most about this problem?

  9. Have you been using the positive characteristics and abilities you mentioned above to deal with this problem? How is that going for you?

  10. What do you suppose has been keeping this problem from creating even more trouble than it already is?

  11. Have you been using your positive characteristics and abilities to help yourself improve the situation when the problem occurs?

  12. Does this problem show up only in one particular place, or have you noticed it appearing elsewhere?

  13. If the problem you have been describing just disappeared right now, how would things be different?

  14. Who are the people you consider to be important in your life? How are they important?

  15. Do you use alcohol or recreational drugs? To what extent? How does this affect you? How do other people you care about react to your use of
    drugs or alcohol?

  16. If you could change anything in your life, what would you change?

  17. Do you like your school or your job? What do you like or not like about it?

  18. What activities are you involved in outside of work or school? How much time do you give to these activities?

  19. Do you have a regular bed-time? Do you have any particular trouble getting to sleep or staying asleep?

  20. How much sleep do you get every night, on average?

  21. Would you describe your eating as generally good or not very good for your health and wellbeing?

  22. What do you consider to be the most traumatic events of your life experience? How did these events affect you? What did you do to help yourself
    recover your health and wellbeing after your experience?

  23. What are your hopes and dreams for your future?

  24. What is your greatest worry or fear for your future?

  25. Please tell me a bit about the family you grew up in:

    1. What were your parents like?

    2. How many brothers and sisters did you have?

    3. What was your birth order position?

    4. What was your parent’s discipline style?

    5. As a child, what were you known for in your family—positively and negatively?

    6. What were the most important values in your family when you were growing up?

  26. Please tell me about the people or family members you are living with now (unless you live by yourself).

  27. What else do you think is important for me to know and appreciate about you?

Thank you very much for answering all of these questions — your responses are very helpful.