Client History Information1

______

Client History Information

Adults

Purpose of this questionnaire:

The purpose of this questionnaire is to obtain a comprehensive picture of your background. By completing these questions as fully and as accurately as you can, you will facilitate your therapeutic program. If the answer space provided is not adequate, please use the backs of the sheets of paper.

It is understandable that you might be concerned about what happens to the information about you because much or all of this information is highly personal. Case records are strictly confidential. NO OUTSIDER IS PERMITTED TO SEE YOUR CASE RECORD WITHOUT YOUR PERMISSION.

If you do not desire to answer any questions, merely write: DCA (Do not Care to Answer).

NAME______AGE______DATE OF BIRTH______

HOME ADDRESS ______ZIP______

HOME PHONE ______SEX M F (Circle one)

SOCIAL SECURITY NUMBER ______

APPROXIMATE FAMILY INCOME BEFORE TAXES $______

EMPLOYER ______

BUSINESS ADDRESS______ZIP______

BUSINESS PHONE______EMAIL ADDRESS: ______

BY WHOM WERE YOU REFERRED?______

WITH WHOM ARE YOU NOW LIVING? (List people)______

______

MARITAL STATUS: (Circle one)

SINGLE ENGAGED MARRIED REMARRIED SEPARATED DIVORCED WIDOWED

If married, husband’s (or wife’s) name______

age______

occupation______

Form Developed by, Dr. Brian Campbell Permission Granted for Clinical Use

Client History Information1

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Name, Address and Telephone Number of a Person who does not live with you but always will know your whereabouts:______

______

RELIGION: a) in childhood______b) as an adult______

FAMILY DATA:

Father: Living or deceased? ______

If deceased, your age at the time of his death?______

Cause of his death?______

If alive, father’s present age?______

Occupation:______

Health:______

Mother: Living or deceased? ______

If deceased, your age at the time of her death?______

Cause of her death?______

If alive, mother’s present age?______

Occupation:______

Health:______

Siblings:

Number of brothers:______Age of brother(s):______

Number of sisters: ______Age of sister(s): ______

Children:

Number of sons:______Age of son(s): ______

Number of daughters:______Age of daughter(s):______

CLINICAL

a) State in your own words the nature of your main problems and their duration:______

______

b) Give a brief account of the history and development of your complaints (from onset to present):______

c) On the scale below, please circle the best estimate of the severity of your problem(s):

Mildly Moderately VeryExtremely Totally

Upsetting Severe Severe Severe Incapacitating

d) Whom have you previously consulted about your present problem(s)?

List name(s) and address(es)

______

______

e) Are you taking any medication? ______

If “yes,” what, how much, and with what results?

______

PERSONAL DATA

a) Mother’s condition during pregnancy (as far as you know).______

______

b) Was the pregnancy normal?______If “no,” what were the problems? ______

c) Was she taking any medication? ______If “yes,” what medication? ______

d) Underline any of the following that applied during your childhood:

Night terrorsBed-wettingSleep-walkingNail biting Fears

Thumb suckingStammeringUnhappy ChildhoodHappy Childhood

Any others?______

e) Health during childhood:

List illnesses:______

f) Health during adolescence:

List illnesses:______

g) What is your present height?______Your weight?______

h) List your main fears:______

______

i) Underline any of the following that apply to you now or in the recent past:

HeadachesCan’t keep a jobSexual problemsNo appetiteAnger

AlcoholismFinancial problemsOver ambitiousNightmaresLonely

PalpitationsExcessive sweatingMemory problemsTake drugsFatigue

Feel tenseStomach troubleInferior feelingsDizzinessAnxiety

Feel panickyUnable to relaxShy with peopleAllergiesInsomnia

Fainting spellsBowel disturbancesOften use aspirin or painkillersConflict

Suicidal ideasCan’t make decisionsHome conditions badTremors

Can’t make friendsDon’t like weekends and vacations

Concentration difficultiesUnable to have a good time

Others: please list additional problems or difficulties here.______

j) Underline any of the following words that apply to you:

Worthless, useless, a “nobody”, “life is empty”

Inadequate, stupid, incompetent, naive, “can’t do anything right”

Guilty, evil, morally wrong, horrible thoughts, hostile, full of hate

Anxious, agitated, cowardly, unassertive, panicky, aggressive

Ugly, deformed, unattractive, repulsive

Depressed, lonely, unloved, misunderstood, bored, restless

Confused, unconfident, in conflict, full of regrets

Worthwhile, sympathetic, intelligent, attractive, confident, considerate

Successful, relaxed, carefree, happy, respected

Others______

k) Present interests, hobbies and activities:______

______

l) How is most of your free time occupied?______

______

______

m) What is the last grade of schooling that you completed?______

Scholastic abilities; strengths and weaknesses:______

______

Were you ever bullied or severely teased?______

n) Do you make friends easily?______Do you keep them?______

OCCUPATIONAL DATA

What sort of work are you doing now?______

______

Kinds of jobs held in the past?______

______

Does your present work satisfy you? ______

If not, in what ways are you dissatisfied?______

______

______

What do you earn?______How much does it cost you to live?______

AMBITIONS

Past______

Present______

SEXUAL DATA

Is your present sex life satisfactory? ______

If not, please explain______

______

Provide information about any significant heterosexual (and/or homosexual) reactions or difficulties:______

Are you sexually inhibited in any way?______

______

Do you have any physical problems that preclude or hinder your sexual activity:______

If so, please specify the nature of this/these problem(s):______

______

MARITAL HISTORY

How long did you know your marriage partner before marriage?______

Husband’s/Wife’s age:______Occupation of husband/wife:______

Personality of husband/wife (in your own words): ______

______

In what area(s) is there incompatibility?______

______

Do any of your children present special problems?______

If yes, please explain:______

______

FAMILY HISTORY

Give a description of your father’s personality and his attitude towards you (past and present):______

Give a description of your mother’s personality and her attitude towards you (past and present):______

Give an impression of your home atmosphere (i.e., the home in which you grew up). Mention state of compatibility between parents and between parents and children.

______

Were you able to confide in your parents?______

Did your parents understand you?______

Basically, did you feel loved and respected by your parents?______

If you have a step-parent, give your age when parent remarried:______

Give an outline of your religious training:______

______

If you were not brought up by your parents, who did bring you up, and between what years?______

Who are the most important people in your life? (List in order.)______

______

Does any member of your family suffer from alcoholism, epilepsy, or anything which can be considered a “mental disorder”?______

If yes, who?______

Are there any other members of the family about whom information regarding illness, etc., is relevant?______If yes, who?______

Recount any fearful or distressing experiences not previously mentioned:______

SELF-DESCRIPTION Please complete the following:

a) I am a person who______

b) All my life______

c) Ever since I was a child______

d) One of the things I feel proud of is______

e) It’s hard for me to admit______

f) One of the things I can’t forgive is______

g) One of the things I feel guilty about is______

h) If I didn’t have to worry about my image______

i) One of the ways people hurt me is______

j) Mother was always______

k) What I needed from mother and didn’t get was______

l) Father was always______

m) What I wanted from my father and didn’t get was______

n) If I weren’t afraid to be myself, I might______

o) One of the things I’m angry about is______

p) What I need and have never received from a woman (man) is______

q) The bad thing about growing up is______

r) One of the ways I could help myself but don’t is______

Is there anything about your present behavior that you would like to change?______

If so, what?______

______

What feelings do you wish to alter (e.g., increase or decrease)?______

______

Have you ever been in therapy before?______

Have you recently experienced any major changes in your life?______

If so, what?______

______

List the benefits/goals you have regarding this consultation:______

Please add any information not addressed in this questionnaire that may aid your therapist in understanding and helping you:______

THANK YOU!

Form Developed by, Dr. Brian Campbell Permission Granted for Clinical Use