6/97 Rev.


1.	Book Title and Subtitle:


2.	Author Information:

	a. Author(s):
   
	b. Author(s) ID (e.g., client, psychologist, writer, family member) :

	c. Gender of author(s):

3.	Publication Information:

	a. Date of publication, current edition: 

	b. Date of original publication, if different:

	c. Approximate date of book writing or disorder:
	
	d. Place of publication:

	e. Name of publisher:

4.	Client Demographics:

	a. Gender:   male     female		

	b. Ethnicity/national origin:
	
	c. Educational level:

	d. Occupational history:
	
	e. Birth order: 	

	f. Marital history:

	g. Any children?:
	
	h. Client's age when first treated for a mental disorder:
	
	i. Client's age when book was written:


5.	Diagnostic Impressions:	

	a. Psychiatric diagnoses given to client if described in book:



	b. Did client agree with the diagnostic labels? 
    Strong agreement    Moderate agreement     Ambivalent     Moderate disagreement      Strong disagreement 
		   Cannot Say


	c.	Any concurrent diagnoses of physical disorders (e.g., chronic pain, seizure disorder)? 
		If so, please indicate:


	
6.	Psychiatric Hospitalization:

	a. Was client hospitalized for the mental disorder?   		Yes	No	Don't know

	b. If yes, how many times and approximate duration of each hospitalization:



7.	Treatments Received:

	a. Individual psychotherapy:					Yes	No	Don't know 
	
	b. Group psychotherapy:			           		Yes	No	Don't know 
	
	c. Family/marital therapy:					Yes	No	Don't know 

	d. Theoretical orientation of primary therapist if known:


	e. Drug treatment, indicate names of drugs if known:		Yes	No	Don't know  


	f. ECT (electroconvulsive therapy) How many times?		Yes	No	Don't know	


	g. Self-help group, indicate name of group(s):			Yes	No	Don't know


	h. Other, please specify:


8.	On the item above (Question 7), rate the client's attitude toward each treatment received      	using the following scale: 1=very negative; 2=somewhat negative; 3=ambivalent; 4= 	somewhat positive; 5=very positive; DK=don't know or cannot rate.

	a.Individual psychotherapy:					1	2	3	4	5	DK
	b.Group psychotherapy:				     	        1	2	3	4	5	DK
	c.Family/marital therapy:					1	2	3	4	5	DK
	d.Theoretical orientation of primary therapist:		        1	2	3	4	5	DK
	
	e.Drug treatment:						1	2	3	4	5	DK
	f.ECT (electroconvulsive therapy):				1	2	3	4	5	DK
	g.Self-help group:						1	2	3	4	5	DK
        h.Other, please specify:			                1	2	3	4	5	DK


9.	To what does the client attribute his/her disorder?  Please use the following scale to rate 	the client's attributed cause of the disorder:  1=strong disagreement; 2=moderate 	disagreement; 3=ambivalent; 4=moderate agreement; 5=strong agreement; DK=don't know 	or cannot rate.

	a. Disorder denied, rejects attribution: 		        1	2	3	4	5	DK
	b. Religious spiritual determinism, e.g. God's will:		1	2	3	4	5	DK 	

	c. Bad luck: 							1	2	3	4	5	DK
	d. Biological problems, e.g. health problems, genetics: 	1	2	3	4	5	DK
	e. Environmental stress, e.g. work or living conditions:	1	2	3	4	5	DK 

	f. Maladaptive cognition, e.g. faulty expectations: 		1	2	3	4	5	DK
	g. Problems in family of origin, e.g. dysfunctional:		1	2	3	4	5	DK 
	h. Interpersonal conflicts, e.g. divorce, relationships:	1	2	3	4	5	DK

	i. Intrapsychic conflicts, e.g. lack of self knowledge:    	1	2	3	4	5	DK
	j. Chosen lifestyle, e.g., chose to be this way:	        1	2	3	4	5	DK
	k. Insufficient effort to change disorder:			1	2	3	4	5	DK

10.	How likely would you be to recommend this book to a client being treated for a disorder   	similar to the one described in the book?
	   Definitely yes      Probably yes      Uncertain      Probably not      Definitely not

11. How likely would you be to recommend this book to a family member of someone with a  	disorder similar to that described in the book?
	   Definitely yes      Probably yes      Uncertain      Probably not      Definitely not

12.	How much did you personally like this book?
	   Like very much      Like somewhat      Neither like nor dislike      Dislike somewhat 
	   Dislike very much

13. If you would recommend this book to a client, are there some types of clients (age, 	gender, diagnosis or anything else) that you feel would profit most from the book? If 
	so, please describe these categories.





14. Name of person reviewing this autobiography:


15. Date of reviewing this autobiography: