RE-ENTRY QUESTIONNAIRE

Name:
   
Email:
      
Mailing Address:
   
Tel. No.
      
Date of Birth:
      
Marital Status:
 
Ages of Children:

Please Type Answers Briefly

1. Date & reason for termination at the Primal Institute:
   
2. Reasons for returning for treatment:
   
3. Psychiatric treatments or hospitalization since leaving the Institute:
   
4. Suicide attempts since termination of therapy (include dates):
   
5. Arrests, indictments, convictions, etc. (describe):
   
6. Problems with drug or alcohol abuse:
   
7. Extreme disability (describe):
   
8. Are you currently taking any prescribed medications (describe)?
   
9. Describe briefly employment history since termination of treatment:
   
10. Date you would like to start re-entry:
   
11. Comments:
   

 

 

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The Primal Institute
10379 Pico Boulevard
Los Angeles, CA 90064

TEL: (310) 785-9456
janov@primalinstitute.com