Identifying Information
In order for us to get to know you more thoroughly and in order to avoid missing any areas that could be of concern to us in dealing with your issues, we ask you to complete the following information. We will review it together in session for further detail.
1. Name ______
2. Today’s Date ______
3. Age ______
4. Date of Birth ______
5. Sex: M______F______
6. Current address ______
7. How long have you lived at your current address? ______
8. Where have you lived for the past five years? ______
9. Place of birth ______
10. Where did you grow up? ______
11. What church do you attend if any? ______
12. What degree of importance do you attach to religious or spiritual values: Very important _____ Important _____ Undecided _____ Not important _____
13. Did you receive religious training as a child? Yes _____ No _____
14. If you received religious training as a child where was the training received? ______
15. Marital Status: Married____ Never Married ____ Separated ____ Divorced ____
16. If you are currently married, how many years/months have you been married? ______
17. What is your spouse’s name ______
18. Age ______
19. Occupation ______
20. Place of birth ______
21. Location your spouse grew up at ______
22. Spouse’s occupation ______
23. Spouse’s employment ______
24. Was your spouse previously married? Yes ___ No ___
25. When ______How long ______
26. How long did you know your spouse or date before marriage? ______
27. List any prior marriage: 1st marriage from ______to ______for _____years,
28. 2nd marriage from ______to ______for ______years,
29. 3rd marriage from ______to ______for ______years,
30. Additional marriages ______.
31. What is your current employment status?
Full time ___ Part time ___ Unemployed ___ Retired ___ Disabled ___
Student ___ Homemaker ___
32. If employed, where are you currently employed? ______
33. Your usual occupation is ______
34. Your current occupation is ______
35. How long have you been employed there and what do you do? ______
36. Previous employment in the past five years: ______
37. Does your income meet your current needs? Yes _____ No _____ if not, why not? ______
38. Where did you go to school? ______
39. What did you major in? ______
40. What degrees do you have? ______
41. Have you had any military service? ______
42. What are your present interests, hobbies, and activities? ______
43. Is occupying free time a problem for you? Yes _____ No _____ if so, why is it a problem, if not, what do you do? ______
44. Do you make friends easily? Yes _____ No _____
45. Do you keep your friends? Yes _____ No _____
46. Is friendship an issue for you in any way? Yes _____ No _____ if so, how? ______
47. Who are your friends? Please list them by first name so we can discuss. ______
48. List by name the people living in your house and their relationship to you: ______
49. Have you or anyone in your family had any prior counseling?
Yes ____ No ____
50. If you or someone in your family have had prior counseling of any type please list by name or relationship who had the counseling and who was the counselor: ______
51. What issues or concerns did any of the above including yourself previously address in counseling and was it helpful or not? Why or why not? ______
52. Other than a counselor whom have you talked with about your issues? ______
53. Are there people that you would like to include in the resolution of your issues if so who are they and how do you want to include them? ______
54. Has your family been broken in any way through death or divorce or any other means? Yes ____ No ____ if so, how has your family been broken? ______
55. What affect has this had on you and your life? ______
56. Is there any history of abuse or violence of any type in your past or your family? Yes _____ No _____ if so, what was the abuse and who was abused? ______
57. Who did the abusing and what was the affect on the abused person? ______
58. Tell me about your father:
59. Name ______
60. Age if living _____
61. Date of death if dead ______
62. How old were you when he died if he is dead _____
63. How well did/do you know your father? ______
64. Is there any other important information about your father that you would like me to know or us to discuss ______
65. Tell me about your mother:
66. Name ______
67. Age if living ____
68. Date of death if dead ______
69. How old were you when she died if she is dead _____
70. How well did/do you know your mother? ______
71. Is there any other important information about your mother that you would like me to know or us to discuss ______
72. Tell me about your brothers and sisters ______
73. Is there anything significant about any of your brothers or sisters that we should discuss? ______
74. Tell me more about what your home life was like growing up: ______(use the backside if you need to add information.)
75. Did you have a stepparent growing up? Yes ___ no ___
76. If so, how old were you when either of your parents remarried, who was the stepparent and how has that relationship been? ______
77. If your parents, did not raise you who did, between what years, and what was that relationship like? ______
78. Describe your spouse, how you met, and what your marriage has been like: ______(use the backside of this sheet if you need to add information.)
79. Tell me about your children. What are their names, how old are they, and where do they live? ______
80. What has parenting been like for you: ______
81. Describe your relationship with any other people that might be significant such as friends, other family members not included above, ex-spouses, employers, church members, etc. ______
82. Who are the most important people in your life currently? ______
83. Does any member of your family suffer from alcoholism, epilepsy, or mental disorders? Yes ___ no ___
84. If yes, please explain: ______
85. Are there any other members of your family about whom information regarding illnesses is relevant or important for us to discuss? ______
86. Date of your last physical exam: ______by Dr.______
87. Results of your exam ______
88. Your usual physician is: ______
89. Has your weight changed significantly is the past year? Yes___no___
90. If so, how? ______
91. Approximately how many hours of sleep do you get per night? ______
92. Do you sleep soundly or do you awaken? ______
93. Describe the medications you are currently taking or have taken in the past six months: ______
94. Have you ever had problems with alcohol or drugs? ______
95. Does any of your family or friends think you have a problem with alcohol or drugs? ______
96. Do you have any legal history that we should be aware of? ______
97. How are your finances? ______
98. In the past two years have you or any one close to you dealt with death, disease, divorce, dishonor, or a disaster of any type? ______
99. Are there any other stressors in your life that we should be aware of? ______
100. As your counselor, is there anything else either prompted from the above questions or currently on your heart and mind that you want me to know or we should be sure to discuss? ______
Signed ______date ______
Reviewed by ______date ______
Memory List
In order to better understand you it is often helpful to look back on your life at the positive or pleasurable memories and the negative or painful memories. Would you please complete a memory list starting at your earliest memory and working your way to today? The list should include those significant memories that stand out as you think about your life. Some memories may be both positive and negative or have both pain and pleasure in them. Memories are stored as pictures or images and felt as emotions or feelings. When you see a memory in your minds eye you may also experience an emotion. As you look back on your life please list the memory briefly and any associated emotion or feeling.
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