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Initial
Request For A Free, Brief Screening Interview -
Information Form
Please copy the
questions below into the body of an email, fill out the
information requested, and send to Dr. Cupchik's
personal email address,
wcupchik@aol.com .
In
the Subject line of the email, please state: "(WC)
Free Brief Screening Interview Request".
The information requested is about the person who has
the problem theft behavior. This information should
be provided in full, to the extent possible, even if the
person requesting the Free Brief Screening Interview is
someone else (a parent, partner, etc...). Please
Note: The
material you provide will not be shared with anyone
else. Only Dr. Cupchik has access to the
email address
wcupchik@aol.com ; that is the email address to
which you should be sending this material. By all means
answer only those questions that you feel comfortable
answering at this time; do keep in mind, however, that
the more complete your answers, the more likely it is
that Dr Cupchik will be able to accurately determine
whether working together is likely to be beneficial to
you.
1.
Your first name:
2.
Age:
3.
Marital Status:
4.
Educational Background:
5.
Your work/profession:
6.
Who in your personal and working lives knows about the
theft behavior?
7.
Describe the sort(s) of theft behavior: (i.e.,
shoplifting, fraud, etc...) that you have engaged in.
8.
How many times you have committed these kinds of acts?
From whom/where have you stolen?
9.
Over what period of time?
10.
Have you ever been caught? Charged? Convicted? How many
times, please:
11.
Your estimate of the total amount, in dollars, of the
value of the items/money stolen:
12.
Issues in your personal and working life that are of
concern to you:
13.
Do you take prescribed antidepressants?
14.
Do you have a problem with alcohol? Street drugs?
15.
Do you have a considerable amount of anger?
16.
Do you tend to be depressed a good deal of the time?
17.
Who in your personal life knows about your problem with
stealing?
18.
Does that person know the full extent of the
problem?
19.
What else can you relate that you think may be relevant
to your stealing behavior?
20.
What other personal issues are of concern to you at the
present time?
21.
When did you last steal?
22.
When did you last get caught and/or charged?
23.
Do you currently have a charge pending before the
courts?
24.
Do you genuinely wish to stop your theft behavior once
and for all or are you primarily
interested in simply dealing with any current charge?
[If the latter, then working with Dr. Cupchik is not
recommended.]
25.
Have you had any previous psychotherapy? What kind,
when, with whom, and what was the duration of the
treatment? What did you learn and how has it helped you
in any area(s) of your life?
26.
Please add below any other information that you care to
and/or that you think Dr. Cupchik should probably be
aware of, when considering your request for the Free
Brief Screening Interview.
Thank you in
advance for taking the time to fill out this form in
detail, and for sending it along in the body of
the email you are planning to send to Dr. Cupchik.
[last updated September 7, 2011] |
