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]