Amitai & Associates, Ltd.
daniel@amitai.net
Last
name Brownell |
First
Katherine |
MI A. |
SS# |
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Address 140 Ingersoll Hall |
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City Ft. Collins |
State CO |
Phone # 970.227.2843 |
E-mail princessaliza@earthlink.net |
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Date of birth 7-1-86 |
Hair color light brown |
Eye color hazel |
Height 5’5” |
Weight 134 |
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QUESTION |
YES |
NO |
1. Do you smoke? |
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X |
2. Do you drink? |
X |
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3. Do you have your own transportation? |
X |
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4. Are you willing to relocate? |
X |
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5. Are you Jewish? |
X |
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6. Do you believe that kissing, making out or having sex with other people besides your boyfriend is acceptable under any circumstance? |
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X |
7. Were you sexually or physically abused as a child? |
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X |
8. Were you raped? |
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X |
9. Are you taking any prescription medication for mental problems? |
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X |
10. Have you ever considered suicide? |
X |
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11. Have you ever attempted suicide? |
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X |
12. Do you cry often (often = any time that doesn’t involve the death of someone you knew) |
X |
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13. Did you lose your virginity before the age of fifteen? |
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X |
14. If you are under 18, have you ever seriously dated or had sex with someone four years older than you? If under 25, someone ten years older than you? |
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X |
15. Do you cut yourself, or practice any other form of self-mutilation? |
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X |
16. Do you have promiscuous sex? |
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X |
17. Are you Down with the Clown till you’re dead in the ground? |
X |
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18. Do you have AIDS or any other inconvenient disease I might contract from you? |
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X |
19. Do you have cancer? |
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X |
20. Are you on The Pill? |
X |
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21. Are you bisexual? |
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X |
22. Have you been diagnosed with any sort of mental disorder? |
X |
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23. Does your mother or father have any diagnosed mental disorders? |
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X |
24. Are you a virgin? |
X |
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25. Do you have a cell phone? |
X |
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26. Did you graduate high school? |
X |
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27. Did you graduate college? |
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X |
28. Are you planning on graduating college in the next four years? |
X |
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29. |
X |
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List your last three ex-boyfriends, starting with the most recent.
NAME |
PHONE NUMBER |
LENGTH OF RELATIONSHIP |
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May I contact your ex-boyfriends to hear all the bad stuff about you? |