If your client has a history of personality disorders, please answer the following :


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Which type of personality disorder has been diagnosed ?
       Antisocial      Narcissistic
       Borderline      Histrionic
       Paranoid        Dependent
       Schizoid        Obsessive/Compulsive
       Schizotypical	  Avoident


   2.  Date of diagnosis ? 


   3.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   4.  Has your client been hospiltalized for
       treatment of a psychiatric illness ? Yes   No 

       If yes, give details: 


   5.  Does your client have a history of any of the following associated conditions ?
        Substance Abuse (alcohol or drugs)
        Mood Disorder
        Suicidal Thought/Attempt
        Other Psychotic Disorder



   6.  Has your client smoked cigarettes in the last 12 months ? Yes   No 


   7.  Does your client have any major health problems ? Yes   No 

       (example: cancer, etc.)

       If yes, give details: