Please answer these questions with honesty and in much detail.  Deborah is not looking for any specific answers, but rather AWARENESS.  Therefore take your time to answer these questions. 

NOTE:  This will remain confidential and will only be read by Deborah.  Therefore feel free to be yourself - that is the key to change. Remember too - putting in the effort to complete this form shows commitment. Commitment means you are half way to achieving what you want.  Therefore at the end of this questionnaire - reward yourself.  You deserve it!