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 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 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 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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Gender	Name	Age	Living / Deceased	If deceased, date of death & cause

Gender	Name	Age	Living / Deceased	If deceased, date of death & cause

Life History Questionnaire

CONFIDENTIAL: “Life History” Questionnaire

General Information

Presenting Problem

Personal and Social History

Children

Friends

Health Care

Religion

Education & Upbringing

Physical Sensations

Consent to Treatment

Your Rights

Limitation on Confidentiality When Treating Couples

Financial Policy