To apply for an interview, please fill in and return the questionnaire and a date for an interview will be sent to you. Please note that whilst it is helpful to have as much information as possible, not everyone feels comfortable with sending personal information to an unknown person. Please feel free to only fill in the information that is required. The required section is highlighted with an asterix. The interview process is for mutual assessment. You and the therapist can explore whatever questions you might need to ask, in order to see if our therapy is appropriate for you. Sometimes it is necessary to have more than one interview. If for whatever reason, it is felt that therapy with one of our staff is not the best option, we will discuss possible alternatives. When you are seen for an interview by one of our psychotherapists you will have the opportunity to talk about your difficulties and why you wish to apply for therapy. We have however, found that it is useful to have some preliminary information and we ask you to provide this by filling in this form and returning it to us should you wish to apply for an interview. IF YOU ARE HAVING DIFFICULTIES FILLING IN THIS FORM, PLEASE CONTACT US ON 0207 267 9616. * NAME: EMAIL: ADDRESS: TELEPHONE (h): TELEPHONE (m): AGE: YOUR GP'S NAME: YOUR GP'S ADDRESS: 1 Who suggested the London Association of Primal Psychotherapists to you? 2 Please describe the nature of your difficulties as you see them. 3 How long have you had them? How are you at present? How have you been at your worst? 4 What aspects of your life give you satisfaction? 5 What times of the day are you available for interviews/sessions? 6 In what way do you hope that primal psychotherapy will work for you? 7 Have you had any previous psychiatric treatment? 8 Has anyone in your family had any psychiatric treatment? 9 Have you had any previous psychotherapy? If so, please give details. 10 Please comment on your physical health. Have you had any serious illnesses or operations? 11 Are you taking any medicines at the moment? 12 Are you taking or have ever taken any non-prescribed drugs? Is there any concern about your drinking? If so, please give details of amount of alcohol consumed and frequency? Do you smoke? If so, how many? 13 Please give us some details of your family. 14 Please tell us something about your mother, her personality and your relationship with her. 15 Please tell us something about your father, his personality and your relationship with him. 16 Please list your brothers and sisters (including half brothers and sisters and step-brothers and sisters). 17 Were there any abortions, miscarriages or stillbirths that you know of? 18 Could you tell us something about your childhood? What changes were there? Were there any important relationships (eg. With grandparents, aunts and uncles, nannies, childminders, friends.) 19 Do you have any information about your birth? eg. Caesarean, forceps. 20 Are you single/living with parent/married/separated/divorced/widowed? 21 If you are or have been married or living with someone, please state for how long, age of husband/wife/partner and his/her occupation: 22 Please tell us something about your partner 23 Do you have any problems or unhappiness in your partnership or family life? If so, please describe this. What aspects of your relationship are good for you? 24 Do you have any sexual problems? 25 Please list your children, including step-children. Please also indicate any stillbirths, miscarriages or abortions. 26 Please tell us something about your children. 27 Please tell us about your schooling and any further education. What kind of experience was it? 28 What is your present employment? What are your plans and prospects in your work? What do you enjoy about your work and what frustrates you? 29 If you were accepted into therapy, how would you finance your therapy. 30 Please tell us anything else you think would be important or useful for us to know.
	LAPP does not accept responsibility for, and does not endorse the content of any external sites linked to the LAPP website. LAPP regrets that it does not respond to requests for therapeutic advice via this web site. You can now email us at info@lapp.org Details that you provide to LAPP will remain confidential and will not be passed to any other organisation.