CONFIDENTIAL PROFILE

Please answer all questions as completely as you are willing. Do not hesitate to ask any questions.

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Name

First Name

Last Name

Have you or any of your family members ever been sexually molested or physically abused?

Choose one.

If yes, who and how many years ago?

If "yes" to the abuse, do you still feel affected by it?

Choose one.

If "yes" to the previous question, please explain.

Have you or any members of your immediate family ever declared bankruptcy?

Choose one.

If "yes" who and what year?

Have you or any member of your immediate family ever served in the military?

Choose one.

If "yes" who and what year?

Has any family member or close friend died within the last year?

Choose one.

If "yes" please provide name and relationship (family/friend).

How close were you?

Choose one.

How many times have you moved in your life?

How many times have you moved in the past year?

Are you or any members of your immediate family currently in therapy or under the care of a doctor or other medical professional?

Choose one.

If "yes" please explain.

Have you or any member of your immediate family had difficulties with alcohol, drugs or eating disorders?

Choose one.

If "yes" please explain, including, if family member(s), who were they?

Please explain how this impacted your life?

LLC - LET'S GET STARTED 3