---
lang: en-GB
papersize: a4paper
geometry: margin=3cm

title: "Lili's BPDemon Collection Intake Form"
---

Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Section 1: Personal Information**

1. Age: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
2. Gender: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
3. Contact Information:
    - Discord: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
    - Twitter: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
    - Phone (Optional): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Section 2: Obsession**

1. How long will you be obsessed with Lili? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
2. How often will you think about this obsession? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
3. Will this obsession cause distress or impairment in your daily life? Yes/No
    - If yes, please describe: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
4. Will you engage in any behaviors related to this obsession that could cause harm to yourself or others? Yes/No
    - If yes, please describe: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Section 3: Treatment History**

1. Have you received treatment for your BPD? Yes/No
    - If yes, please describe: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
2. Are you currently in treatment for your BPD? Yes/No
    - If yes, please describe: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Section 4: Consent**

I, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, hereby consent to the use of this evaluation form for the purpose of assessing my application. I understand that the information provided in this form will be kept confidential and used only for the purpose of vetting my application.

Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
