SCREENING INTERVIEW QUESTIONNAIRE
This questionnaire is not to be copied or used by
any other professional without the explicit permission of Dr
Cupchik. [Dr Will Cupchik© 2013]
If you genuinely
believe you may be an 'Atypical Theft Offender' and assuming
that the cost of the Program you would be inquiring about is affordable for you,
then please fill out the questionnaire below and email to
is intended only for persons considering taking either of the
Programs referred to above and
who wish to apply for the Free Brief Screening Interview
to help determine whether you would be a suitable applicant to
take the Program.
It is suggested that you copy this Questionnaire
and place it into a Word document where you can then answer the
questions. Then simply copy the now-completed Questionnaire and
email it to me. In the subject line of your email,
please write the following:
[(WC) My completed FBSI Questionnaire]
After reading your
responses, I will reply via email and if I believes that taking
the Program may be of assistance, I will email you back and
suggest possible times for the proposed Free Brief Screening
Interview to take place. If I do not think that the Program may
be suitable, then I
will so advise, via email.
1. First name only
(at this time): _______________
_____________ / __________
Educational Background: _____________________________________
Have you ever stolen from your workplace, your co-workers,
clients or customers?
Describe the sort(s) of theft behavior: (i.e., shoplifting,
fraud, etc...) that you have engaged in.
How many times in total you have committed these kinds of acts?
From whom (relatives, friends, strangers, etc…?) and where (kind
of stores, elsewhere) have you stolen?
Over what period of time? ____________________ years
10. Have you ever
been caught? ___________
11. Have you ever been charged?
12. Have you ever
been convicted? __________ When, where and how many times,
13. Your estimate of
the total amount, in dollars, of the value of the items/money
14. Issues in your
personal and/or working life that are of concern to you:
15. Do you take
prescribed antidepressants? ____________ If so, which one?
_____________ Dosage? _______________ For how long have you been
taking this medication? _______________ What other
prescribed medications are you taking?
16. Did you ever
steal before being on an antidepressant? ______________
17. Did you steal
only after you began using an antidepressant?
18. Did/do you have
a problem with alcohol? ____ ___ Street drugs (which ones)?
19. Do you have a
considerable amount of anger? _____________ If so, towards whom?
20. Do you tend to
be depressed a good deal of the time? ______________________
21. Who in your
personal life knows about your problem with stealing?
22. Does that person
truly know the full extent of the problem?
23. What else can
you relate about yourself and the goings on in your personal
life, that you think may be relevant to your stealing behavior?
24. What (other)
personal issues are of concern to you at the present time?
25. When did you
last steal? ___________________
26. When did you
last get caught and/or were charged? __________________
27. Do you currently
have a charge pending before the courts? ___________ If yes,
then in what jurisdiction (country, state or province)? Details
of the charge, please…
28. Have you
ever spent any time in jail for stealing offences? _________ How
many separate times, and for how much time in total?
29. Have you been
convicted of any other offences? Please describe…
30. Do you genuinely
wish to stop your theft behavior once and for all or are
you primarily or only interested in simply dealing
with any current charge? ______________________ [If the latter,
then working with Dr Cupchik is definitely not recommended]
31. Have you had any
previous psychotherapy? ___________ Are you currently in
therapy? ________ What kind, when, and what was/has been the
duration of the treatment?
32. 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.
33. Since you
have been using a prescribed antidepressant, has your stealing
markedly increased, lessened or stayed about the same?
34. How would you
describe the state of your primary relationship? (Strained,
supportive, in trouble, etc…)
How supportive do you think your partner would be if he/she knew
the full extent of your stealing?
he/she really know the FULL extent of your theft
36. Which Program [
(a) the Skype-based full Intensive Interventional Program, (b)
the Skype-based Individualized Educational Program or the (c)
in-office full Intensive Interventional Program] are you
interested in inquiring about?
And what are your primary concerns in relation to considering
37. Where (in what
country, state or province) do you live?
38. Does the
jurisdiction in which you live have a so-called 'three-strikes
policy' for criminal behavior, including shoplifting?
39. I understand
that the Free Brief Screening Interview is offered only
to persons who might benefit from taking the Program and
for whom the funds required for
the professional fee involved are not an issue.
I have read
the relevant pages on the
website, am aware of the current cost of Program that I am
primarily interested in and payment of the fee is
not an issue for me should we agree, following our Free Brief
Screening Interview, that taking the program might well be
appropriate for me.
I agree:________ I do not agree: