Code PR TAYLOR—JOHNSON TEMPERAMENT ANALYSIS® PROFILE

Profile Revision of 1984

Name &-4tZZ Age _.3 sex_

School_______________ Grade Degree Major Occupation Cou

Single........... Years Married _ Years Divorced........... Years Widowed._...... Children: M Ages

Answers made bjjjnd husband, wile, father, mother, son, daughter, boyfriend, girlfriend or

the person described.

A B C D E F G I

Mids C 10

Raw score 3:3 3o ' 7 4 'c

pHost ile

Rawscore

Percentile /S /5' c 's- Percentile

TRAIT Nervous Depressive Social Responsive

Sympathetic Subjective Dominant disdphn TRAIT

95 'I------- -I--- - 90 _ 90 ____ _________ _______

85 85 80_-___ _________ _______ 80 75 ----- ---.-- --75 70 70 65 65 6 60

55 55

5 50

45 45

40 40

35 35

30 30

20 20

11111111 II:EIIIy.JI-EH OPPOSITE

Composed hLed

Quiet Inhibited Indifferent Objective Submissive Tolerant Impulsive OPPOSITE

I I Excellent Acceptable Improvement desirable

Improvement needed

DEFINITIONS

TRAITS

Nervous - Tense, high-strung, apprehensive.

Depressive - Pessimistic, discouraged, dejected.

Active-Social - Energetic, enthusiastic, socially involved.

Expressive-Responsive - Spontaneous, affectionate, demonstrative. Sympathetic— Kind, understanding, compassionate.

Subjective - Emotional, illogical, self-absorbed.

Dominant -Confident, assertive, competitive.

Hostile— Critical, argumentative, punitive. Self-disciplined - Controlled, methodical, persevering.

OPPOSITES

Composed—Calm, relaxed, tranquil. Light-hearted - Happy, cheerful, optimistic.

Quiet - Socially inactive, lethargic, withdrawn.

Inhibited - Restrained, unresponsive, repressed.

Indifferent - Unsympathetic, insensitive, unfeeling.

Objective - Fair-minded, reasonable, logical.

Submissive - Passive, compliant, dependent.

Tolerant — Accepting, patient, humane.

Impulsive— Uncontrolled, disorganized, changeable.

Note: Important decisions should not be made on the basis of this profile without confirmation of these results by other means.

Published exclusively by Psychological Publications, Inc., 290 Con ejo Ridge Avenue, Suite 100, Thousand Oaks, California 91361-4928. Copyright © 1967, 1984 by Psychological Publications, Inc. All rights reserved. Reproduction in whole or part prohibited. Taylor-Johnson Temperament Analysis® is a registered trademark of Psychological Publications, Inc. Printed in the U.S.A.

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MILLON CLINICAL MULTIAXIAL INVENTORY-11 FOR PROFESSIONAL USE ONLY

ID NUMBER = 58 VALID REPORT PERSONALITY CODE =7w*3*14+6a5tI8E6A2sA//_*t_*// SYNDROME CODE = - ** - * // - ** - * // DEMOGRAPHIC = 58 /OT/F/3 3/W/D/C4/C/MA/--/ -----/--/io/----- / 630000007

SCORE CATEGORY - -

RAW BR

x217 15 DN

Y 16 75 F'

EE z 0 0

I 17 66

2 3 4

3 32 79

4 21 62 CE LRP

S A 5 20 37 N 0 T

NT CAE ÔA 6 4 ALR

N T 6B 18 41 V

7 44 90

SA 3 4

SB 6 29

P p 2 14 SEA ERT VSH C 3 14 ENL RLO ETG p 1147

YY

A 1 27

H 4 55

N 13 41

D 2 27 AM LE B 6 4

T 8 12

SS 0 2 s EN VU cc 0 2 ER R E M pp 4 37

E

DIAGNOSTIC SCALES

lao

DISCLOSURE

DESIRABILITY

DEBASEMENT

SCHIZOID

A VO IDA NT

DEPENDENT

HISTRIONIC

NARCISSISTIC

ANTISOCIAL

AGGRESSIVE/SADISTIC

COMPULSIVE

PASSIVE-AGGRESSIVE

SELF-DEFEATING

SCHIZOTYPAL

BORDERLINE

PARANOID

ANXIETY DISORDER

SOMATOFORM DISORDER

BIPOLAR:MANIC DISORDER

DYSTHYMIC DISORDER

ALCOHOL DEPENDENCE

DRUG DEPENDENCE

THOUGHT DISORDER

MAJOR DEPRESSION

DELUSIONAL DISORDER

/r pack MCMI-II reports are normed on patients who were in the early phases of assessment or psychotherapy because of emotional discomforts or social difficulties. Respondents who do not fit this normative population or who have inappropriately taken the MCMI-II for nonclinical purposes may have distorted reports. To optimize clinical utility, the report highlights pathological characteristics and dynamics rather than strengths and positive attributes. This focus should be kept in mind by the referring clinician reading the report.

Based on theoretical inferences and probabilistic data from actuarial research, the MCMI-II report cannot be judged definitive. It must be viewed as only one facet of a comprehensive psychological assessment, and should be evaluated in conjunction with additional clinical data (e.g., current life circumstances, observed behavior, biographic history, interview responses, and information from other tests). To avoid its misconstrual or misuse, the report should be evaluated by mental health clinicians trained in recognizing the strengths and limitations of psychological test data. Given its limited data base and pathologic focus, the report should not be shown to patients or their relatives.

INTERPRETIVE CONSIDERATIONS

In addition to the preceding considerations, the interpretive narrative should be evaluated in light of the following demographic and situational factors. This 33 year old divorced white woman with a college education, reports her most recent problems as Marital or Family; difficulties appear to have taken the form of an Axis I disorder of an unspecified duration.

Unless this patient is a well-functioning adult who is facing minor life stressors, her responses suggest not only an effort to present a socially acceptable front but also an intense resistance to admitting personal shortcomings. Inclined to view psychological problems as a sign of emotional or moral weakness, the patient self-protectively denies any unseemly traits or symptoms. This probably reflects either a broad-based concern about being appraised unfavorably by others or an active suspicion of the arcane motives of psychological inquiry. MCMI-II scores have been adjusted to compensate for this patient's unusual defensiveness, but the overall profile may remain partially distorted. An interpretation based on standard interpretive procedures is likely to be reasonably valid, but may fail to represent certain features of either the patient's current disorders or character.

NATIONAL COPYRIGHT 1976, 1981, 1983, 1985. 1987 by Theodore Millon. This report COMPUTER COPYRIGHT 1991 by Theodore Millon. All rights reserved. Scored by SYSTEMS a National Computer Systems, Inc. P.O. Box 1294, Minneapolis, MN 55440

MCMIM11 as Millon Clinical Multiaxial Inventory-I) f)' A rons

Theodore Milton, PhD.

Copyright © 1976. 1981, 1983, 1985. 1987 - Theodore Millon. All rights reserved. jHrinn

DIRECTIONS FOR REFERRING CLINICIAN 1. Complete the following information and any demographic data 3. Note DURATION of current episode and period of therapy,

not completed by the test taker in the section below. 4. Fill in SETTING/STATUS and IDENTIFICATION NUMBER

2. Record your best Axis I and II DX using OSM-Ill codes. (usually Social Security number).

DIAGNOSTIC CODE PRE.MCMI-]E DX IMPRESSIONJ

AXIS AXIS 11

0000000000

1-DURATION OF RECENT AXIS I EPISODE

- .1

2-PERIOD OF MOST RECENT THERAPY

2

Less than one week 00 One to four weeks 30 One to three months 3O Three to twelve months DO Periodic; one to three years 3 Q Continuous; one to three years

Periodic; three to seven years DO Continuous; three to seven years 00 More than seven years

Cannot categorize

IDENTIFICATION NUPSWER

000000000

DO ®®® 00 S®

DO®

Outpatient never hospitalized)

Outpatient previously hospitalized)

Inpatient (mental hospital)

(general hospital)

Correctional Inmate

College Student Counselee

a a

DIRECTIONS FOR TEST TAKER — 1. Please fill in the circles that apply in each section below, with many types of problems. When you agree with a

Do not mark the special sections on the upper pan of this statement or decide that it describes you, fill in the ® to

page; this is for your doctor to complete. mark it true 15 ®)• If you disagree with the statement or a

2. Use a soft, black load pencil only and make a heavy, dark decide that it does not describe you, fill in the ® to mark a mark when filling in the circles, it false (® 5). Try to mark every statement even if you a

3. If you make a mistake or change your mind, please erase are not sure of your choice. If you have tried your best and a the mark fully and then fill in the correct circle, still cannot decide, mark the ® for false, a

4. The following pages contain a list of statements that people 6. There is no time limit for completing the inventory, but a use to describe themselves. They are printed here to help it is best to work as rapidly as is comfortable for you. a

you in describing your feelings and attitudes. Try to be as 7. This form will be scored by computer and the results will a

honest and serious as you can in marking the statements be sent directly to your doctor where they will be kept a

since the results will be used to help your doctor in learning confidential, a about your problems and in planning to help you. 8. You may begin with the first statement on the next page a

S. Do not be concerned that a few of the statements will after filling in the information requested in the boxes ONE

seem unusual to you; they are included to describe people below. S a

S AGE MARITAL LAST

I

RACE E STATUS

X Never Married ø' • White a

3 First Marriage h School lii a

M D€ 3 Remarried C) Slack a

DC 3 separated Technical School a

E C S Divorced 00 C) Hispanic a

0 • C) widowed Business School a

€ 3 Cohabitating ®® ® 3 Asian 3 Muslim a F

D CE 3 Other College a

M .g DO®00040 CE 3 American a

DI! Graduate Indian S

E 2®®®CE —

ScorForni '45120 a

LI a a S

. . U U Now

SI *tEMS Marital or Family C) 3 Protestant

C) Job/School/Work 3 3 Loneliness 3 •Catholic

3 Moodiness C) 3 Self-Confidence 3 3 Jewish

3

III/Tired Q 3 Alcohol 3 3 Drugs 3

Sexual Problems 3 Other 3 3 3 Anti-Social Behavior 3 3 Other 3

0* I always follow my own ideas

rather than do what others expect

— of me.

®• lye always found it more

comfortable to do things quietly

— alone instead of with others.

— a®• Talking to other people has almost

-M always been difficult and painful

— for me.

M 40(D I believe in being strong willed and

— determined in everything I do.

— 5 0* In the last few weeks I begin to cry

even when the slightest of things

— goes wrong.

— 60*Some people think of me as a

conceited and self-centered

— person.

— (Do As a teenager, I got into lots of

— trouble because of bad school

— behavior.

— 8 ® 0 I always feel I am not wanted in a

group.

g ® 0 I often criticize people strongly if

— they annoy me.

— io®*l am content to be a follower of

others.

— iiO Si enjoy doing so many different

things that I can't make up my mm

what to do first.

— 120* Sometimes I can be pretty rough

— and mean in my relations with my

— family.

Ø5 I have little interest in making

friends.

14*01 think I am a very sociable and

out-going person.

15051 know I'm a superior person, so

I don't care what people think.

lGØØPeopIe have never given me

enough recognition for the things

I've done.

have a drinking problem that I've

tried unsuccessfully to end.

isO Lately. I get butterflies in my

stomach and break out in cold

sweats.

have always wanted to stay in

the background during social

activities.

200*1 will often do things for no reason

other than they might be fun.

21 5® I get very annoyed with people

who never seem able to do things

right.

220* If my family puts pressure on me.

I'm likely to feel angry and resist

doing what they want.

230*1 often feel I should be punished

for the things I have done.

24®* People make fun of me behind my

back, talking about the way I act

or look.

z5Ø*Other people seem more sure than

I am of who they are and what they

want.

26001 tend to burst out in tears or in

anger for unknown reasons.

21Ol began to feel lonely and empty

about a year or two ago.

280*1 have a talent to be dramatic.

29O 0 I have a hard time keeping my

balance when walking.

30®l enjoy intense competition.

3 1 Q5When I run into a crisis, I quickly

look for someone to help me.

32051 protect myself from trouble by

never letting people know much

about me.

33Ol feel weak and tired much of

the time.

34*® Other people get more angry

about bothersome things than

I do.

35ØMy drug habits have often gotten

me into a good deal of trouble in

the past.

360* Lately. I find myself crying without

any reason.

310*1 think I'm a special person who

deserves special attention from

others.

3805 Under no circumstances do I ever

let myself be tricked by people who

say they need help.

395Øone sure way to make a peaceful

world is by improving peoples

morals.

40&J5ln the past I've gotten involved

sexually with many people who

didn't matter much to me.

410*1 find it hard to sympathize with

people who are always unsure

about things.

— I

0

[-I

U U

42l®lama very agreeable and

submissive person.

4301 My own 'bad temper has been a

big cause of my troubles.

44011 don't mind bullying others to get

them to do what I want.

45OFor the past few years even minor

things seem to depress me.

46 01 My wish to get things done just

perfectly often slows down my

work.

4101 I'm so quiet and withdrawn, most

people don't even know I exist.

48011 like to flirt with members of the

opposite sex.

4900 I am a quiet and tearful person.

590 I'm a very erratic person, changing

my mind and feelings all the time.

51011 feel very tense when I think of the

day's happenings.

52•®Drinking alcohol has never caused

me any real problems in my work.

53(DO Lately, my strength seems to be

draining out of me, even in the

morning.

54011 began to feel like a failure some

years ago.

55011 strongly resent "big shots" who

always think they can do things

better than I can.

5600' have always had a terrible fear

that I will lose the love of people

I need very much.

seem to go out of my way to let

people take advantage of me.

sgؕLately, I have begun to feel like

smashing things.

59011 have given serious thought

recently to doing away with myself.

60011 am always looking to make new

friends and meet new people.

61011 keep very close track of my money

so I am prepared if a need comes

up.

62011 was on the front cover of several

magazines last year.

63OlFew people like me.

64C?JlIf someone criticized me for making

a mistake, I would quickly point out

some of that person's mistakes.

osOtSome people say I enjoy suffering.

fifiØl often let my angry feelings out and

then feel terribly guilty about it.

si®•Lately, I feel jumpy and under

terrible strain, but I don't know why.

53011 very often lose my ability to feel

any sensations in parts of my body.

59011 believe there are people who use

telepathy to influence my life.

70®Taking so-called illegal drugs may

be unwise, but in the past I found

I needed them.

it ®Øl feel tired all the time.

72(D* I can't seem to sleep, and wake up

just as tired as when I went to

bed.

iaQl I've done a number of stupid things

on impulse that ended up causing

me great trouble.

140*1 never forgive an insult or forget

an embarrassment that someone

caused me.

isl®We should respect earlier

generations and not think we know

better than they.

16011 feel terribly depressed and sad

much of the time now.

7701 1 am the sort of person that others

take advantage of.

780(D I always try hard to please others,

even when I dislike them.

ioOlSerious thoughts of suicide have

occurred to me for many years.

30011 quickly figure out how people are

trying to cause me trouble.

0101l've always had less interest in sex

than most people do.

82011 can't understand it, but I seem to

enjoy hurting persons I love.

8301A long time ago, I decided it's best

to have little to do with people.

84011 am ready to fight to the death

before Id let anybody take away

my self-determination.

asOlsince I was a child, I have always

had to watch out for people who

were trying to cheat me.

BfiOlWhen things get boring. I like to

stir up some excitement.

81011 have an alcohol problem that

has made difficulties for me and

my family.

as® hf a person wants something done

that calls for real patience, they

should ask me.

8901 1 am probably the most creative

thinker among the people I know.

9000 1 have not seen a car in the last

ten years.

9101 1 don't see anything wrong with

using people to get what I want.

92Olpunishment never stopped me

from doing what I wanted.

931®There are many times, when for no

reason, I feel very cheerful and

full of excitement.

9401 1 ran away from home as a teenagel

at least once.

95011 very often say things quickly —

that I regret having said. —

osOl In recent weeks I feel worn out —

for no special reason. —

gi®ØFor some time now I've been a

feeling very guilty because I a

can't do things right anymore. a

gaOhIdeas keep turning over and over

in my mind and they won't go —

away. —

9900 I've become quite discouraged

and sad about life in the past a

year or two. —

1000* Many people have been spying intoa

my private life for years. a

10104 1 don't know why, but I sometimes —

say cruel things just to make a

others unhappy. —

10201 1 hate or fear most people. a

1034®I speak out my opinions about a

things no matter what others a

may think. —

I04 ®4When someone in authority a

insists that I do something, I'm a

likely to put it off or do it poorly a

on purpose. a

ios®My habit of abusing drugs has a

caused me to miss work in the a

past. a

iosl®I am always willing to give in to a

others to avoid disagreements. a

101011 am often cross and grouchy. a'

103011 just don't have the strength to a

fight back anymore. a

10901-ately, I have to think things a

over and over again for no good a

reason. a

ito01 1 often think that I don't deserve a

the good things that happen a

to me. —

11 01 1 use my charm to get the a

attention of other people. a

11201When I'm alone, I often feel the a

strong presence of someone a

nearby who can't be seen. a

113®•l feel pretty aimless and don't a

know where I'm going in life, a

ii®•lately. I've been sweating a a

great deal and feel very tense. a

iisOlsometimes I feel like I must do a

something to hurt myself or —

someone else. a

11601 lye been unfairly punished by a

the law for crimes I never a

committed. a

11701I've become very jumpy in the a

last few weeks, a

11301 1 keep having strange thoughts a

that I wish I could get rid of. a

a

a

a

0 U U •

0

Ua

— ii90l have a great deal of trouble

trying to control an impulse to

drink to excess.

— 12001 Most people think that rn a

— - worthless nothing.

21011 can get very excited sexually

when fighting or arguing with a

loved one.

1225®l have succeeded over the years

in keeping my drinking of

alcohol to a minimum.

1230*1 have always tested" people to

find out how much they can be

trusted.

1240* Even when I'm awake. I don't

seem to notice people who are

near me.

125 It is very easy for me to make

many friends.

25501 always make sure that my

work is well planned and

organized.

niQS I very often hear things so well

that it bothers me.

12805 My moods seem to change a

great deal from one day to the

next.

1 2905 1 don't blame anyone who takes

advantage of someone who

a allows it,

13005 I've changed jobs more than

three times in the past couple

of years.

13105 1 have many ideas that are

ahead of the times.

132 (DO For some time now rye been

feeling sad and blue and can't

seem to snap out of it.

iaaOSI think it is always best to seek

help in what I do.

1340*1 often get angry with people

who do things slowly.

135Ql really get annoyed with people

—2 who expect me to do what I —

don't want to do.

01 13605 In the last few years, I have

—

felt so guilty that I may do

—

something terrible to myself. — Ca

131051 never sit on the sidelines when

—> IllCE) People tell me that I'm a very

I'm at a party.

proper and moral person.

13905 1 sometimes get confused and

feel upset when people are kind

to me.

14005 My use of so-called illegal drugs

has led to family arguments.

051 am very ill-at-ease with

members of the opposite sex.

05 There are members of my

family who say I'm selfish and

think only of myself.

•®l don't mind that people are not

interested in me.

Q5Frankly. I lie quite often to get

out of trouble.

Ø5People can easily change my

ideas, even if I thought my mind

was made up.

05 Others have tried to do me in,

but I have the will power to

overcome them.

®l My parents often told me that I

was no good.

051 often make people angry by

bossing them.

• ® I have great respect for those in

authority over me.

051 have almost no close ties with

other people.

151 (DO People have said in the past that

I became too interested and too

excited about too many things.

52051 have flown across the Atlantic

thirty times in the last year.

153051 believe in the saying, "early to

bed and early to rise..."

1540S1 deserve the suffering I've gone

through in life.

155 00 My feelings toward important

people in my life often swing

from loving them to hating them.

15601 My parents always disagreed

with each other.

167050n occasion I have had as many

as ten or more drinks without

becoming drunk.

15805 In social groups lam almost

always very self-conscious and

tense.

159501 think highly of rules because they are a good guide to follow.

16005 Ever since I was a child, I have

been losing touch with the real

world.

161011 rarely feel anything strongly.

162051 used to be really restless,

traveling around from place to

place with no idea of where I

would end up.

630(Z) I can't stand people who are late

for appointments.

16405 Sneaky people often try 'to get

the credit for things I have done

or thought of.

1 6500 1 get very irritated if someone

demands that I do things his way

rather than my own.

I have the ability to be successful

in almost anything I do.

isiOl Lately, I have gone all to pieces.

168 (DO 1 seem to encourage the people

I love to hurt me.

16905 There has never been any hair

on either my head or my body.

170 (DO When lam with others I like to

be the center of attention.

171 (DO People who I admired greatly at

first have often become real

disappointments to me later.

11205 I'm the kind of person who can

walk up to anyone and tell him

or her off.

113501 prefer to be with people who

will be protective of me.

17400 I've had many periods in my life

when I was so cheerful and used

up so much energy that I fell

into a low mood.

75QI have had difficulties in the past

stopping myself from over-using

drugs or alcohol.

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—U U U U U U •

/ / Softcover Answer Sheet Handscoring

r Si Hathaws J.C. McKinley

NATIONAL COMPUTER SYSTEMS

DIRECTIONS:

Please follow these directions when completing the

identification areas on this page and responding to the

MMPI-2 items on page 3.

1. Print your name, birth date, age, sex, and testing date

in the area on the right side of this page.

2. Use a pencil only and make a dark mark when responding

to the items on page 3.

3. If you make a mistake or change your mind, please

erase the mark fully and then fill in the correct circle.

4. Please do not make any marks outside the circles.

PcLskt f/z . heytA

Last Name First Middle

33 Birth Date Age Sex

? / 9r Test Date

MINNESOTA MULTIPIIASIC PERSONALiTY INVENTORY2 Copyright -by THE REGENTS OF THE UNIVERSITY OF MINNESOTA

1942, 1943 (renewed 1970), 1989. This Answer Sheet 1989. All Rights Reserved.

Distributed Exclusively by NATIONAL COMPUTER SYSTEMS, INC. Under License from The University of Minnesota

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24018

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22 05 123 12405 125

126 ® 121 128 129 ® 13005 131 132 S® 3305

134 '35 OS

• MARKING DIRECTIONS:

• Make dark, heavy marks that completely fill the circle.

• Use a soft, black lead pencil.

• Erase mistakes cleanly.

13805 13105 1380 139

1415® 142

' 43 5® 14404 14505 14605 141 05 148 149®5 soØ5

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153 (DO 0*

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LI) - 3

LIFE HISTORY QUESTIONNAIRE

Please antter the following questionnaire, so that your psychologist can develop a comprehensive treatment plan. if you do not desire to answer any question : yet' can write "do not care to answer."

Date

1. General Information:

Name:

Address:

Telephone numbers: (day) 7T7-533o (eve.) V'/?-7JL. Age: 3 Occupation: r'Ac/o __c.-,--',_-

Who do you live with? (list people) n7 50&

Marital Status: (circle one) Singla. engaged, married, remarried, separated,

C-Rv'orce'd) widowed

If married, husband's (wife's) name, age, occupation;

2. Clinical:

a) Please describe the nature of your main problems and their duration: 't e4 c,nc4ovnc JZJLj6]'M3

b) Give a summary of the h±tory and development of your complaints (from onset to present):

2L ck.\ &s rr, sa K's

c) On the scale below, please estimate the severity of your problem(s):

mildly upsetting moderately severe very severe extremely severe Totally incapacitating_____________

d) Whom have you previously consulted about your present problem(s)?

- Hit ôz;. ,4sae - SAidt 0e4-4r&4 Toseph &LI'€,eO Pe th.4cc&&J

e) Are you taking any medication? If "yes," what, how much, and with what results?flD

f) Please list dates of any previous psychotherapy or psychiatric hospitalizations:

n

Page Two

3. Personal Data;

a) Date of birth: C f3 (O Place of birth; ót*ncA 9'y r'n;ckja .ci

b) Underline any of the following that applied during your childhood:

Ni t terrors

fears

bedwetting Nail biting

ldhoo dij_~)

unhappy childhood Sleepwalking stammering Spec. Education classes Victim of Child Abuse

c) Health during childhood and adolescence? List illnesses: Chcta'c.' ?c, Tn -a-' 95

d) Any current medical problems? Please list. n(4

e) Any surgical operations? (Please list them and give age at the time)

C.see4to.-- ,

f) How much alcohol do you drink in an average week? Cton4_

g) Any accidents and/or head injuries? If so, explain. tnteo& c!a4C. 4864 t'c# e $Iit

, no

h) List your five main fears: flJ34j %Cn- cr.c..a14 kLsct- a94Ai

'-h t e nocvncLCA;g 3)1ck 4ccJej an&oc kuc4..jos bM-L,

i) Underline any of the following that apply to you:

headaches palpitations bowel disturbances anger nightmares tension depression inability to relax don't like weekends & vacations

can't make friends can't keep a job financial problems excessive sweating mood swings allergies excessive worrying

dizziness stomach trouble fatigue take sedatives feel panicky conflict suicidal ideas sexual problems overambitious inferiority feelings short-term memory problems

long-term memory problems

loneliness often use aspirin

or painkillers

fainting spells anxiety no appetite insomnia alcohol problems tremors take drugs shy indecisive home conditions bad unable to have

a good time concentration

difficulties unusual eating habits preoccupation with weight

Page Three

Others: Please list additional problems or difficulties here.

h) Underline any of the following words which apply to you:

Worthless, useless, a "nobody," "life is empty"

Inadequate, stupid, incompetent, naive, "can't do anything right"

Guilty, evil, morally wrong, horrible thoughts, hostile, full of hate

Anxious, agitated, cowardly, unassertive, panicky, aggressive

Ugly, deformed, unattractive, repulsive

Depressed, lonely, unloved, misunderstood, bored, restless

Confused, unconfident, in conflict, full of regrets

WorthwhiLe, svmathetic, intelligent, attractive, confident, considerate

1) Present interests, hobbies, and activities: Wmn n a.n.nçGn. It.Aiorc) en C4tsctcS .. t.ec ccJtctl. 3ejc

50a?c 13e3 t&c4c, ..et ç0z5ç

J) How do you spend your free time? 6-v rnbJtes -4za.cL ,ceCats:n.3 ,

1.' PLOA.t .IeCA, i4t

K) What is the last grade of school you completed?Co%A

1) What kind of grades did you receive in high school? gaodftA&)b&e4 LJ/KCACtS

in) What were your strongest subjects?

n) What were your weakest subjects? nts44k.,, eti1 LsL,

o) If you did not complete high school, please state why:

p) Were you ever bullied or severely teased?_______________________

q) Do you make friends easily? Do you keep them?__________

r) Have you ever been arrested? P0 If so, please provide details:__________________________________ (use back of paper if necessary)

4. Occupational Data

a) What are yoAkr career goals? ConTh + cAgotC44kL

&C9&L-a A&tflht t+-.nC tJtk U ScJ0L ik 4 b) What What is your plan to achieve these goals? .l't co.tJv%......., JA UZA

~l

Page Four

c) Please list your last 3 jobs beginning with your current position:

Type of Position Dates of Employment 1. RZOSCufr.creckl4oj. YYtajCt K , 1q7q —

Reason for ps'cse1cr

Leaving c#toa.o e..,L.t 0r pd.cT

2 • CttD.OLktSOt't'k'C 4..q. I9'$ -z'aMqy

3. eouoibuLsc ~ otT/flL -;47q4/ff(

— d) What do you earn? it

3-1-f IfOO /ydj

What does it cost you to 1ive? 0

5. Sex Information

a) Parents attitudes toward sex? oe

t.,-s atscc4&cjx

b) When and how did you derive your first knowledge of sex? 5cAo0L15e.c edc.ct-&_1

&h00L- CaP.-C4' , c) When did you first become aware of your own sexual impulses? h&ScJwt,L

d) Did you ever experience anxieties or guilt feelings related to sex? p'b

e) Please list any relevant details regarding your sexual experiences.

f) Is your present sex life satisfactory? (If not, please explain) pz -

g) Provide information about any significant heterosexual and/or homosexual interactions:

h) Are you sexually inhibited in any way? p.

6. Menstrual History

Age at first period? tc ?

Were you informed or did it come as a shock? wa&La. w'Mitn.t.& t-

- Do your periods affect your moods? ?tnS êj0eessc 1 rb

7. Marital History be- if.

How long did you know your spouse before getting married?

How long tessyou been married?

(Hu~sbDand' wife's age: 34?

Occupation o ' n or wife: cs-ems A041 sT

a) Please describe the personality of your spouse:

b) In what areas is there compatibility?

c) In what areas is there incompatibility?

- Page Five

d) Row may children have you? Plase list their sex and ages. I c2k ta T1e1 ezlS.

e) Do any of your children present special problems?

f) Any relevant details regarding miscarriages or abortions? n0

g) Please list dates of previous marriages: SepT (ctlI_ Sept 119

h) Briefly describe circumstances of any separations or divorces: 3çc&.. cSLkjC)ftCJt,

8. Family Data

a) Father: gLtksto

Occupation: .L4ZMAZt411_t&, lOoL #-t-e_ IL4r,tSS 15dt s.

Health:

If deceased, your age at the time of his death?

Please describe your current relationship with your father: e(osc. 4-

r4?ttiodJ../qo ~vTh pat4s çrt

b) Mother:

Occupation: Stca.Ja#- ck0.L- 5p4etL

Health: qaDo

Please describe your current relationship with your mother: C/054L t

uj C.- 4aUC rc4n,i- eA c4Lt.

If deceased, your age at the time of her death?

c) Siblings;

Number of brothers: /

Brothers' ages; 3/

Number of sisters: / - Sisters' ages:_

d) Give a description of you. A

fathet' perscnality: "_g, g -5 tocst -fhai. his LjOutS 5tic /ou4tt9i-.4oLr I-n.s b&c. * KL4 bta& . to-'es 1014 let

e) Give a description of your m(dther's personality: LcueSpec1k, n &hiaJ-, Stha.L,

f) In what ways did your parents punish you when you were a child? 5pfrnt..t5 4 S4ta-p.

g) Please describe your family atmosphere while you were growing up: (Include your relationship with parents & siblings) LARn.j

,

a.3C)?hSa , Cst.t. fite S%ch 5ccten

I2t/a9rn.sAp '-/4o# s1o.3pad ttA/ej,ioc ,p ct'.ks

h) Did you feel loved and respected by your parents?

Page Six

i) Were you brought up by anyone other than your parents? If so, during what years? ,,

J) Does any member of your family suffer from alcoholism, depression, epilepsy, or any other mental disorder? A.0

k) Are there any other mzmbers of the family about whom additional information is relevant? (-c)

1) Please describe any fearful, distressing, or traumatic experiences not previously mentioned: tk

m) Have you ever lost control of your emotions or behavior? If so, please describe.

- poac /&tt.a..c. gecoxrc.d c

n) Please Please describe your personality and temperament:CC.t¼. bc .

cc-i.- . a..pet4'eecnZst 44S9,rAJ, 5,L -M4s - W4- 4orT fl 4A9% 1 :14. 4o

o) Please describe ?our current social relationshiP7.

*-a.,j ~ ctaao hh.c rDt, t..jtc 5La. -

.4_ta..nlj. C(os.'i4.

qt**> 4-1 01 .ct¼ kk 4-j pks;c.it.ts p) Please add any additional information that is relevant to your life:

9. Sentence Stems:

a) I am a person who e'%ojs Lk, 1;ui.s Ac £' o-r4 Acr-1u>c j -ã

e1s b' b) Ever since I was a child- r.d \-eg' 55\4na cvt& 5o,rcb ~t

c) One of the things I feel proud of is- 4.4 a.. wo..t', CMLL(t.. pLL(o#..J 4-

d) It's hard for me to admit t 4k&4- i CAn nO-k SD çp 4-,i-,r'- bc-CC PC4.€Q€AJ

e) One of the things I can't for ive is- 4i-lo 2ev-c evt4

&4k Ltr1 n tIW4t *.

- f) One of the things I feel guilty about is hO+ picL. op 5aOoecocctot5 ctbu-sc

g) If I didn't have to worry about my im:ge -hkv4 i-&.'ot& aLaocn n AqI.d1kt.

h) Sex - 12ZivaJC cSv€

i) Mother was always 4'KQ tiJ&•4 &L -Jt-M-u.it-¼1 4octIScp/LQ

dv C1 ?o- ' pact-'4s J.'ppn& inc n - tcsjLc. J) What I needed from mother and didn't get was CIt.tcd 9uPffi

k) Father was always - Mw4q ,4d Aazo ,,,4k ours.4, At;-I OQ &ut doti 0 41-ct..4t/d flu ariá&9

1) What I wanted from myather and didn't get was •F AeS.c&4 n-cckd

,90, 60t,04t&zt5. m) The worst thing that ever happened to me was - Sti cte!Cl deed L.*k

4e.i 4 L4) r '4pe PAc tFbc fg.t ped. n) One of the things stopp.ns me from making positive changesis vY\. -

70e an-i -4., flioQ h c'aJj'Qnn