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Have you ever sought help or been concerned about your drinking or drug usd? 0 Yes LINO If so,describe what concerned yo21-u: <br /> SEXUAL/ PHYSICAL/EMOTIONAL ABUSE: <br /> Do you have any history of sexual abuse? CI Yes 0 No <br /> Have you ever been physically abused? CI Yes r] No <br /> Have you ever been emotionally abused? 1=1 Yes El No <br /> IS THERE ANYTHING ELSE YOU WOULD LIKE YOUR THERAPIST TO K VOW ABOUT YOU? <br /> . . <br /> Page 3 of 3 <br />