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Personal Information
First Name
Last Name
Full Address
Home Phone
Work Phone
Physical History
General Health
Are you now under a doctor's care? No Yes
If yes, name of doctor
Reason for Doctors Care
Are you taking any medication? No Yes
If yes, What Kind
Reason for Medication
Last Medical Examination
Have you ever been hospitalized for a physical illness? No Yes
Any recent major illnesses or surgeries?
Any recurrent or chronic conditions?
Do you smoke? No Yes
Do you take drugs? No Yes
If yes, What Kind
Do you take drink? No Yes
How Much
Any Previous Therapy/Counseling? No Yes
If yes, describe, when, where, how long, what for
What do you hope to achieve with therapy?
Work History
How Long?
If presently unemployed, describe the situation?
Family Systems Information
Where born
How long there
Ethnic ID
Father Alive? No Yes
Where residing
Mother Alive? NoYes
Where residing
Marital Status
Number of marriages
Spouse's name
Living with a partner No Yes
How Long
Partners Name
#1 Male Female Age
#2 Male Female Age
#3 Male Female Age
#4 Male Female Age
#5 Male Female Age
#1 Male Female Age
#2 Male Female Age
#3 Male Female Age
#4 Male Female Age
#5 Male Female Age
Family Alcoholism or Domestic Violence? No Yes
Sexual Addictions or Abuse No Yes
Parents divorced? No Yes
If yes, what year?
Your age at the time?
If deceased, what year?
Cause of death
Any step-parents? No Yes
If yes, describe when and your relationship with them
If reared by someone other than your birth parents, describe the situation in some detail Tell anything else in the space below that you think would be helpful for me, as your therapist, to know.
Spiritual History
Religious upbringing
Present Affiliation
Is this an important part of your life? No Yes
Why not ?
Emotional Status
Are you currently experiencing strong emotions? No Yes
If yes, describe
Do you make decisions based on your emotions? No Yes
How well does that work for you
Did you have what you would consider to be childhood or other traumas? No Yes
If yes, describe
Have you been treated for emotional disturbances? No Yes
If yes, when
Have you had any thoughts of suicide No Yes
Do you have any thoughts now No Yes
Present Situation:
Please state why you decided to come for counseling/therapy
What is the nature of your situation
What would you like to experience that is different from what you are experiencing now
How long has this been a problem for you
Please state what you would like to work on in therapy
Personal Agreements

I have read and agree to the above terms  

Signature Date