Client History Information1
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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