PREVIOUS THERAPY INFORMATION
Have you ever been severely emotional upset? Yes _______ No _______
If yes, when? ____________________ What happened? _____________________
_________________________________________________________________________
_________________________________________________________________________
Have you previously been in therapy? Yes _______ No _______
1) Agency/Center ________________________ Therapist ______________________
Address ________________________________________________________________
City __________________________ State __________________ Zip _________
Reason for therapy _____________________________________________________
Number of sessions ____________ Dates _________________________________
Satisfaction ___________________________________________________________
2) Agency/Center __________________________ Therapist ____________________
Address ________________________________________________________________
City __________________________ State __________________ Zip _________
Reason for therapy _____________________________________________________
Number of sessions ____________ Dates _________________________________
Satisfaction ___________________________________________________________
PERSONALITY INFORMATION
Circle any of the following words which seem to describe you NOW--in your current circumstances:
ACTIVE AMBITIOUS SELF-CONFIDENT PERSISTENT HARD-WORKING
NERVOUS IMPATIENT IMPULSIVE MOODY OPTIMISTIC EXCITABLE
CREATIVE CALM SERIOUS EASY-GOING PESSIMISTIC SHY/QUIET
INTROVERT EXTROVERT LIKEABLE LEADER AGGRESSIVE DEPRESSED
SUBMISSIVE SELF-CONSCIOUS LONELY SCARED SAD ANGRY
Other words which come to mind: __________________________________________
___________________________________________________________________________
Circle any of the following words which seem to describe you IN GENERAL--in more usual circumstances:
(Check here if the same as above: ______)
ACTIVE AMBITIOUS SELF-CONFIDENT PERSISTENT HARD-WORKING
NERVOUS IMPATIENT IMPULSIVE MOODY OPTIMISTIC EXCITABLE
CREATIVE CALM SERIOUS EASY-GOING PESSIMISTIC SHY/QUIET
INTROVERT EXTROVERT LIKEABLE LEADER AGGRESSIVE DEPRESSED
SUBMISSIVE SELF-CONSCIOUS LONELY SCARED SAD ANGRY
Other words which come to mind: __________________________________________
___________________________________________________________________________
FAMILY HISTORY INFORMATION
Answer this section describing your parents or guardians.
Father Mother _Step-Parent _
Name|________________|________________|________________|
Still living?| Y N Age _____| Y N Age _____| Y N Age _____|
Where (City/State)|________________|________________|________________|
If No, yr/age at death|Yr ____ Age ___ |Yr ____ Age ___ |Yr ____ Age ___ |
cause of death|________________|________________|________________|
your age at death|________________|________________|________________|
Education (# of years)|________________|________________|________________|
Occupation|________________|________________|________________|
Nationality background|________________|________________|________________|
Religion|________________|________________|________________|
Church attendance/month| 0 1 2 3 4 5+ | 0 1 2 3 4 5+ | 0 1 2 3 4 5+ |
If applicable, describe your parent's marriage now
Unhappy _______ Average _______ Happy _______ Very Happy _______
Answer this section describing your childhood.
Were you raised by both your biological parents? Yes _______ No _______
If not, were you raised by (please check)
Father|Mother Explain, if needed: _____________
single parent(s) |______|______| _________________________________
step parent(s) |______|______| _________________________________
adoptive parent(s) |______|______| _________________________________
foster parent(s) |______|______| _________________________________
guardian(s) | | | _________________________________
Were your parents divorced? Yes _____ No _____ How old were you? ______
Was your childhood home broken by the death of either of your parents?
Yes ___ No ___ If yes, Who? Father Mother How old were you? ______
If applicable, rate your parents' marriage while you were growing up
Unhappy _______ Average _______ Happy _______ Very happy _______
Explain, if needed: ____________________________________________________
_________________________________________________________________________
As a child did you feel closest to your
Father _____ Mother _____ Another _____ Who? ________________________
Describe your childhood life
Unhappy _______ Average _______ Happy _______ Very Happy _______
Explain, if desired: ___________________________________________________
_________________________________________________________________________
List your brothers and sisters by order of birth, including yourself:
___________________________________________________________________________
Name Age Step/ Sex Living? Where? Emotionally Marital
_________________1/2? ______ ________ City/State _ close to you?_ Status
| | | M F Y N Y N ? S M W D
| | | M F Y N Y N ? S M W D
| | | M F Y N Y N ? S M W D
| | | M F Y N Y N ? S M W D
| | | M F Y N Y N ? S M W D
| | | M F Y N Y N ? S M W D
| | | M F Y N Y N ? S M W D
| | | M F Y N Y N ? S M W D
Thank you for your time and patience in filling out this form.
It will be valuable in providing background information for your therapist.
Signature ___________________________________ Date _______________________
