Therapy in Los Angeles

Specializing in EMDR, EFT, Hypnotherapy,
Family and Relationship Therapy and Life Coaching

Susan Quinn, MA, MFT

SUSAN QUINN M.A., M.F.T.

TEL: 310-600-3458
E-MAIL: susan@susanquinn.net

ASSESSMENT FORM
Free Therapy Consultation

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Required Question(s)


Please check all that apply

After being happy with your lifestyle for years are you finding yourself feeling confused and trapped?
Would you like to find new meaning in your life, based on what works for you in this chapter of your life?
Have you lost interest in things that used to bring you joy?
Would you like help finding new meaning in your life?
Do you create the same relationships over and over with different people?
Would you like to know how to revive the intimacy and excitement in your relationship?
Is it hard to open emotionally to another person?
Are you constantly looking and not finding the right person?
Do you feel like you're a bad person?
Do you need help knowing how and why to leave a relationship?
Have you been abused as a child?
Do you think about food all day?
Do you think that if you just lost weight you could accomplish anything?
Are you afraid to leave the house?
Do you find it hard to silence the chatter in your mind?
Have you gotten into trouble for your anger?
Do you want to feel more vital and alive?
Do you worry about the future?
Are you afraid of change?
Do you have a hard time concentrating?
Do you find other people getting a promotion when you are the one who is more qualified?
Other

Comment:

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First Name

Home Phone

Email Address
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Improve your life now! Complimentary 20 minute phone consultation.

After you fill out this assessment form I will call you to book a consultation.

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Susan Quinn : 310-600-3458

E- mail: susan@susanquinn.net

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