Refuse To Quit.com -- Refuse To Quit and Life Surrenders!









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Please take your time to thoughtfully complete the following Confidential Client Questionnaire. The information you provide will be the basis for my response to you. All information will be kept completely confidential and is only seen by James E. Coston and/or the assigned REFUSETOQUIT.com therapist. However, if you are uncomfortable answering any of the questions, please do so to the best of your ability and answer only what you feel is most relevant to the problem.

I have read and agree to the disclaimer / consent form


Name (what you would like me to call you) : *

E-Mail Address: *

Date of Birth: ( ex: 06/01/70) *

City / Town where you live:

State	Country

Gender:
Male	Female
Please describe the main reason you are seeking counseling and/or coaching from REFUSETOQUIT.com, including your questions, as clearly as you can:
*If you know what you would like to happen, please tell me here :**
Have you had any type of mental health services in the past:
Yes	No
If yes, please describe when, for what and how(if) it was helpful:
Relationship Status:
Other type of relationship or special circumstances (please describe)

Do you have children:
Yes	No
If so, list gender and ages

Living Arrangement: how many people do you live with and what is there relationship to you:

Employment Status:
Do you enjoy your work:
Yes	No	Somewhat
Type of work you do:

Highest level of education received:
List any health problems you have:

Please list any medication you take:

Do you drink alcohol:
Yes	No
If you do, how much and when:
Do you use any other substances:
Yes	No
Other relevant information regarding substances, past or present

How did you hear about REFUSETOQUIT.com

*Are you seriously considering suicide at this point:(required)**
Yes	No
IF YOU ARE SERIOUSLY CONSIDERING SUICIDE, E-COUNSELING IS NOT APPROPRIATE FOR YOU RIGHT NOW. PLEASE CALL THE NATIONAL SUICIDE HOTLINE AT 1-888-248-2587, A SUICIDE HOTLINE IN YOUR AREA OR CALL 911.

* field is required