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IF YOU ANSWERED"NO",SKIP TO QUESTION M4. <br /> IF YOU ANSWERED"YES",CONTINUE WITH QUESTION M2. <br /> M2. When did you most recently consult with a mental health professional? <br /> a. Currently consulting a therapist/counselor <br /> b. Within the last 12 months, but no longer consulting a therapist/counselor <br /> c. Between two and five years since my last meeting with a therapist/counselor <br /> d. Six or more years since my last meeting with a therapist/counselor <br /> M3. What were the main reasons that initially led you to contact the mental health <br /> professional?(MARK ALL THAT APPLY.) <br /> a. Marital/relationship with romantic partner problems <br /> b. Problems with children <br /> c. Job related problems • <br /> d. Problems with parents/parental caretakers <br /> e. Depression <br /> f. Anxiety <br /> g. Stress from work or home <br /> h. Anger management problems <br /> i. Alcohol-related problems <br /> j. Use or abuse of illegal drugs <br /> k. Abuse of prescription drugs <br /> I. Traumatic event <br /> m. Identity problems/self insight <br /> n. Eating disorder(bulimia, anorexia) <br /> o. Suicide attempt <br /> p. Phobias(for example,fear of heights, closed spaces) <br /> q. Other psychological problems <br /> M4. Have you ever been hospitalized for psychiatric or psychological reasons(for example, <br /> suicide attempt)at any time in your life? <br /> a. No <br /> b. Yes <br /> M5. Were you ever required (by the courts, your employer, the military,workers compensation, <br /> or other reason)to be evaluated and/or treated by a mental health professional because of <br /> your behavior, or alleged behavior? <br /> a. No <br /> b. Yes <br /> M6. Have you filed claims or lawsuits for compensation (including disability or workers <br /> compensation)in which your psychological or emotional well being was an issue? <br /> a. No <br /> b. Yes <br /> PSS/LEPS PLLC 96 <br />