Brief details of previous relationships:
Any children? yes no
How many? none 1 2 3 4 5 6+
Any significant problems with any of these children?
List children's name, age, gender:
Any history of abuse (emotional, physical, sexual) in current of previous relationships?
Role of religion and/or spirituality in childhood:
Role of religion and/or spirituality as an adult:
State in your words the nature of you main problems and how long they have been present:
Give a brief history and development of your complaints (from onset to present):
Please check the severity of your problem(s) mildly upsetting extremely severe moderately severe totally incapacitating very severe
Whom have you previously consulted about your present problem(s)?
Are you taking any medications? If "yes", what, how much, and with what results?
Health during childhood? List illnesses:
Health during adolescence? List illnesses:
Any drastic changes with your weight?
Any surgical operations? (please list them and give the age at the time:
Check any of the following that apply to you:
Is there a family history of mental illness? If so please indicate who and what their illness was:
Any family history of drug and/or alcohol use? Who?
List your five main fears
Present interests, hobbies and activities
How is most of your free time occupied?
Do you belong to any clubs organizations?
Were you ever bullied or severely teased? yes no
Do you make friends easily? yes no
Do you keep your friends? yes no
What is the last grade of school that you completed?
Scholastic abilities: strengths and weaknesses?
Describe your school experiences:
Were there any problems with truancy, suspensions, special education, vocational training, etc?
What sort of work are you doing now?
List previous jobs:
Does your present work satisfy you? (If not, in what ways are you dissatisfied?)
Do you experience worry or stress over your finances?
If on a leave of absence or disability, will you return to your present job? -- choose -- Yes No
How long did you know your marriage partner before engagement?
How long have you been married?
How long have you been in a common-law relationship?
Describe the personality of your partner (in your own words):
In what areas is there compatibility?
In what areas is there incompatibility?
How do you get along with your in-laws? (This includes brothers and sisters-in-law)
Any history of miscarriages or abortions?
Is your father still alive? yes no
If deceased, your age at the time of his death?
If deceased, cause of his death?
If alive, father's present age, occupation and health?
Is your mother still alive? yes no
If deceased, your age at the time of her death?
If deceased, cause of her death?
If alive, mother's present age, occupation and health?
Number of brothers none 1 2 3 4 5 6+
Number of sisters none 1 2 3 4 5 6+
Relationship(s) with brothers and sisters: Past
Relationship(s) with brothers and sisters: Present
Give a description of your father's personality and his attitude toward you (past and present)
Give a description of your mother's personality and her attitude toward you (past and present)
In what ways were you punished by your parents as a child?
Give impressions of your home atmosphere
(i.e. the home in which you grew up, including compatibility between parents and between parents and children):
Were you able to confide in your parents?
Did your parents understand you?
Basically, did you feel loved and respected by your parents?
If you have a step-parent, give your age when your parent remarried:
Describe your religious training:
If you were not raised by your parents, who did raise you, and between what years?
Has anyone (parents, relative, friends) ever interfered in your marriage, occupation etc.?
Who are the most important people in your life?
Does any member of your family suffer from alcoholism, epilepsy, or anything which can be considered a "mental disorder"?
Are there any other members of the family about whom information regarding illness, etc., is relevant?
Recount any fearful or distressing experiences not previously mentioned?
What do you expect to accomplish from therapy, and how long do you expect therapy to last?
List any situations which make you feel calm or relaxed
Have you ever lost control (e.g. temper or crying or aggression)? If so, please describe.
Please add any information that may aid me in understanding and helping you