Dr. Carol Clark

Be In Light

The offspring of a customized orbiter
Dr. Carol Clark is a Board certified sex therapist and addictions counselor; and president and senior instructor for Therapy Certification Training, the International Transgender Certification Association, and the International Institute of Clinical Sexology.
Our over-stimulated lifestyles have led to a disconnection from each other and the Universe. The themes and exercises in this book will help you to Connect and be present, leading to a more fulfilled and peaceful life.
Welcome to the Sex Therapy Training Institute (STTI) website. We are pleased you have chosen to learn more about the finest, most comprehensive training programs available today.
CAP training for interns and licensees to qualify for the ICRC exam.
Go to TherapyCertificationTraining.org and take your clinical career to the next level!
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History Form

Fields marked with an asterisk (*) are required.



This is a long form, If you have a slow or intermittent connection please be advised that if you are disconnected you will loss your data


Client's Name(*)

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Date Of Birth(*)

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(MM/DD/YYYY), do hereby seek and consent to participate in treatment by Dr. Carol L. Clark PA. I understand the nature of the treatment to which I am consenting and have been informed of the potential advantages and disadvantages of that treatment. I have had an opportunity to ask all my questions and have received satisfactory answers to all of my questions.
E-Mail Address(*)

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PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS AS FULLY AS POSSIBLE. YOUR ANSWERS ARE COMPLETELY CONFIDENTIAL EXCEPT AS REQUIRED BY LAW (PLEASE REVIEW THE HIPAA NOTICE OF PRIVACY PRACTICES) THE PURPOSE OF THIS QUESTIONNAIRE IS SO I CAN TREAT YOU AS EFFECTIVELY AND EXPEDITIOUSLY AS POSSIBLE.



YOUR HISTORY


Previous psychological episodes, treatment providers and treatments:

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Current psychological concerns, treatment, medications

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Personal or family related help/counseling/ therapy: When: # sessions: With whom/credentials Problems you consulted them for Type of therapy received Satisfaction with, difficulties, outcomes.

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Hospitalizations/home rest for “nervous breakdowns”/suicide attempts/social agency contacts:

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Education History: High School: College: Technical School:

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Work History Name of employer: Job title: Salary: How long: Why left: Repeat for last five jobs

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Alcohol and other drug use What drug: How much used: How often: Have you tried to cut down or quit: When: Any treatment: Repeat for alcohol and each drug used.

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History of Abuse: verbal, physical, sexual, marital, elder, childhood, family of origin, level of violence.

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Legal History/Trouble with the law/police # of arrests Charges: Convictions: Sentences? Litigation anticipated, pending or in past, especially against therapists. Lawyer’s name/#:

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Health: Major current and historical health problems: When: How treated: By whom: Allergies? All current medications: (over the counter, prescription, daily and rarely) Name of medication Dosage: How often: What for:

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Date of last exam by an physician:

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Family of Origin: Where were you raised: Who raised you: # of brothers and sisters and their ages: Any domestic violence: Any alcohol or substance abuse:

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Please say a little about each of the following, regarding your family while growing up: affection, control, discipline, expectations, aspirations, personalities, mental health, abuse, religion, schooling, occupations, marriages, legal. Important friendships:

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Health of family members: Chronic illnesses, Deaths: Parent’s/relatives health - especially similar (to your) problems.

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Current marriage/family situation How met: Type of relationship: How long: Changes: Stressors: Domestic violence: Alcohol or substance abuse:

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Number and ages of children, problems or concerns

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Anything I haven’t asked about that is relevant/important/I should know?

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Have you thought about hurting yourself any time in the past 30 days? Describe:

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Have you thought about hurting anyone else in the past 30 days? Describe:

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Eating patterns, exercise, sleep? How often: How well: Any concerns:

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Ambitions? Goals? Work satisfaction? Please say a little about each.

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What do you hope therapy will do?/Outcome(s) of treatment? (expectations, harmony of)

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What do you want to change about yourself? Aspects of your life (strengths, resources, abilities, supports, education, employment, feelings, behaviors, developmental stage, relationships.)

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How important do you feel these changes are? (Rank these changes by importance.)

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How long do you think these changes will take?

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How does therapy work? What do you think a therapist should be like?

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Major crises of last 1-5 years and how you handled them:

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When are you happy?

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What persons, ideas or forces have been most useful/influential to you in the past?

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Current positives in life? (Hobbies? Sports? Family? Security?)

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Spiritual or religious issues? Existential concerns? Influence of culture?

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