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Life History Questionnaire
CONFIDENTIAL: “Life History” Questionnaire
Please fill out whatever is applicable to you.
General Information
Today's Date
MM slash DD slash YYYY
Name
First
Last
Gender
Female
Male
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth
MM slash DD slash YYYY
Referred By
First
Last
Phone (home)
Phone (work)
Phone (cell)
Marital Status
Single
Engaged
Cohabitating
Married
Separated
Divorced
Widowed
Please check all that apply.
Are you a student?
Yes
No
Where are you studying?
Where are you studying?
Are you employed?
Yes
No
Full or part time?
Full time
Part time
Employer
Occupation
Employment Start Date
MM slash DD slash YYYY
Employer Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Presenting Problem
What do you hope to accomplish in counseling?
Please estimate the severity of your problems
Mildy upsetting
Moderately upsetting
Very upsetting
Extremely upsetting
Totally upsetting
When did your problems begin? Please give dates.
Please describe significant events occurring at the time, or since then, which may relate to the development or maintenance of your problems.
So far, what solutions to your problems have been most helpful?
Have you been in counseling before or received any professional assistance for these or other problems? If so, please give names, professional titles, dates of treatment and results.
Have you ever been hospitalized for psychological problems?
Yes
No
When and where were you hospitalized?
Personal and Social History
Siblings
Gender
Name
Age
Living / Deceased
If deceased, date of death & cause
Please list all of your siblings by sex, name, age and if they are still living. For those deceased, please give date and cause of death
Is your father living?
Yes
No
What is your father's age?
What is the state of your father's health?
What is or was your father's occupation?
How old was your father at the time of his death?
How old were you at the time of his death?
What was the cause of his death?
Is your mother living?
Yes
No
What is your mother's age?
What is the state of your mother's health?
What is or was your mother's occupation?
How old was your mother at the time of her death?
How old were you at the time of her death?
What was the cause of her death?
Do you currently have a partner?
Yes
No
What is your partner's name?
Partner's age
Partner's occupation
What's the state of your relationship?
Partnered
Engaged
Married
Separated
Divorced
When were you married?
How long did you know one another before your engagement?
When did your divorce or separation begin?
Children
Do you have children?
Yes
No
Children
Gender
Name
Age
Living / Deceased
If deceased, date of death & cause
Please list all of your children by sex, name, age and if they are still living. For those deceased, please give date and cause of death
Friends
Do you have one or more friends with whom you feel comfortable sharing your most private thoughts and feelings?
Yes
No
Health Care
Do you have a family physician?
Yes
No
Physician's address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Do you own a gun?
Yes
No
Religion
What was your religion as a child?
What is your religion as an adult?
Education & Upbringing
Last grade completed
Degree?
How would you describe your academic performance?
Excellent
Above Average
Average
Low Average
Poor
What were scholastic strengths and weakness?
Did you date much in high school?
Yes
No
Did you date much in college?
Yes
No
N/A
Which of these applied during your childhood/adolescence:
Happy childhood
Unhappy childhood
Emotional / behavior Problems
Legal problems
School problems
Family problems
Strong religious convictions
Medical problems
Alcohol abuse
Drug abuse
Does any member of your family suffer from, Alcoholism, Epilepsy, Depression, Mental Disorders? If yes, please describe:
Are you currently (or have ever been) in an abusive relationship?
Yes
No
Have you experienced sexual abuse any time in your past?
Yes
No
Have you ever attempted suicide?
Yes
No
Has any relative attempted or committed suicide?
Yes
No
Has any relative had serious problems with the law?
Yes
No
Physical Sensations
Choose any of the following that often apply to you:
Headaches
Stomach trouble
Skin problems
Dizziness
Dry mouth
Palpitations
Muscle Spasms
Tension
Sexual disturbance
Bowel disturbances
Tingling
Numbness
Fatigue
Twitches
Back pain
Fainting spells
Hearing things
Watery eyes
Flushes
Burning or itchy skin
Chest pains
Rapid heartbeat
Blackouts
Excessive sweating
Visual disturbance
Hearing problems
Tics
Please describe any current concerns about your physical health.
Please list any medications or supplements you are currently taking, or have taken during the past six months include aspirin, birth control, prescription or over the counter medicines.
Please describe any accidents or injuries that effect your health.
Have you ever had any head injuries or loss of consciousness?
Yes
No
Please describe the nature and dates of these injuries.
Have you had surgery?
Yes
No
Please give details and dates for your surgery/surgeries.
Do your periods affect your mood?
Yes
No
Please share any relevant information about abortions or miscarriages.
Which of these substances have you used in the past year:
Marijuana
Tranquilizers
Sedatives
Aspirin
Cocaine
Painkillers
Alcohol
Coffee
Cigarettes
Narcotics
Stimulants
Hallucinogens, LSD
Which of these conditions have you experienced in the past year:
Diarrhea
Constipation
Allergies
High blood pressure
Heart problems
Nausea
Vomiting
Insomnia
Headaches/backaches
Overeating “junk foods”
Early morning awakening
Fitful sleep
Overeating
Poor appetite
Consent to Treatment
I do hereby seek and consent to take part in the treatment or evaluation of myself or my child and I agree to play an active role in this process.
Your Rights
I am aware that I may stop my treatment with my therapist at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.) I also have the right to ask questions about my therapist's clinical background and qualifications or questions about any procedures or methods used in treatment.
Limitation on Confidentiality When Treating Couples
There are slightly different expectations and limits about confidentiality in couple therapy than there are in individual therapy. In couple therapy the couple is the client. For instance, if there is a request for the treatment records of the couple, I will need the authorization of both members before I release confidential information. Also, if my records are subpoenaed, I will assert the therapist-patient privilege on behalf of the couple, not just an individual.
During the course of therapy with a couple I may see either individual alone for one or more sessions. These sessions are a part of the couple therapy. These sessions are confidential in the sense that I will not release any confidential information to a third party unless I am required by law to do so or unless I have your written authorization. However, I may need to share information learned in an individual session with both members of the couple, if I am to effectively serve the couple being treated. I will use my best judgment as to whether, when, and to what extent I will make such disclosures and will also, if appropriate, first give the individual the opportunity to make the disclosure. Thus, if you feel it necessary to talk about matters that you absolutely want to be shared with no one, you might want to consult with a different therapist who can treat you separately.
This “no secrets” policy is intended to allow me to treat the couple more effectively by preventing, to the extent possible, a conflict of interest that might arise if an individual’s interests are not consistent with the interests of the couple being treated. For instance, information learned in the course of an individual session may be relevant or even essential to the proper treatment of the couple. If I am not free to exercise my clinical judgment regarding the need to bring this information to the couple during their therapy, I might be placed in a situation where I will have to terminate treatment. This policy is intended to prevent the need for such a termination.
I acknowledge by my signature below that I have read this policy, that I understand it, that I have had an opportunity to discuss its contents with our therapist, and that I enter therapy in agreement with this policy.
Financial Policy
Please take a few minutes to read this to avoid misunderstandings about payment.
Current rate is $175 per 45-minute session and is always expected and required at the time of your visit.
You may pay cash, check or Visa, MasterCard or American Express. If you would like to automatically use your credit card as payment each time you come, you will need to complete the portion of this form below.
Checks returned by your bank are subject to a
$20.00 processing charge
. Accounts unpaid after
30 days
from the date of billing may be subject to a finance charge at the rate of
0.5% per month (6% per annum)
. Accounts with an outstanding balance of
90 days are automatically referred for collection
. If your account must be referred to an outside agency for collection, you will be responsible for collection costs up to
30%
of the outstanding balance, together with court costs and reasonable attorney’s fees.
If you are not able to keep a scheduled appointment and do not give at least 24 hours notice or fail to show up for your scheduled appointment, you are subject to being charged for the missed appointment. If you are a member of a group,
you will be billed for every session the group convenes whether you attend or not
.
We would like to take this opportunity to welcome you and assure you that we will do our utmost to provide you with the best care possible.
I have read and understand the Financial and Consent to Treatment Policy.
*
Yes
No
Client Name:
*
Date Signed:
*
MM slash DD slash YYYY
Signature of Client or Responsible Individual:
*
Name
This field is for validation purposes and should be left unchanged.
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