Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate *

MM

DD

YYYY

Phone *

(###)

###

####

Passport Expiration Date *

MM

DD

YYYY

9. Do you consider yourself one or more of the following (check all that apply)? *

Introvert

Extrovert

Intuitive

Decisive

Fact Oriented

Perceptive

Feeling

Intellectual

10. The following list contains some of the many experiences that may have touched your life. Please check all boxes that apply to your life experience, even if they are "one time" experiences. *

Violent Behavior

Sexual Abuse

Physical Abuse

Emotional/Spiritual Abuse

Anxiety

Depression

Obsessive/Compulsive Disorder

Bipolar Disorder

Eating Disorder

Suicidal Thoughts

Suicidal Attempts

Pornography

Alcohol Addiction/Abuse

Prescription Abuse

Illegal Drug Use

Homosexual Feelings

Homosexual Activity

None of the Above