Collateral Questionnaire for a Loved One or Family Member

Collateral Questionnaire For A Family Member

  • Collateral Questionnaire

    Your loved one is presently undergoing a psychological evaluation with Dr. Paul Simpson. As part of this assessment, it is particularly helpful for Dr. Simpson to interview you for additional perspective. Please be as honest as possible in your answers. Your effort on this questionnaire helps Dr. Simpson to create a more accurate and helpful assessment. Let’s start with some basics:
  • MM slash DD slash YYYY
  • Social Influences:

  • Intimate Relationship

    (Only answer this section if you are married or partnered with this person.)
  • MM slash DD slash YYYY
  • General

  • Substance Use

  • Impulsive Tendencies

  • Problem Solving

  • Sexual History

  • Pornography

  • Various

  • Sexual Interests

  • (Some people are sexually aroused by items, such as high-heels, stockings or rubber and some are aroused by engaging in certain activities such as urinating on another person or wearing clothes of the opposite sex.)