LIFE HISTORY QUESTIONNAIRE

The purpose of this questionnaire is to obtain a comprehensive understanding of your life experience and background. Completing these questions as fully and accurately as possible will benefit you through the development of a treatment plan suited to your specific needs. Please return this questionnaire on your next visit for review and discussion. PLEASE COMPLETELY FILL OUT THE FOLLOWING PAGES Name: !ate:

"hat do you want to gain from counseling#

"hat is the role of religion and$or spirituality in your life: Check any of the follo !n" that a##l!e$ $%&!n" yo%& ch!l$hoo$' Night Terrors %edwetting &leepwalking 'rrational (ears Thumb &ucking Nail %iting Nervous %ehavior )air Pulling )appy Childhood *nhappy Childhood +ational (ears ,ggression "hat was your health condition during childhood# )ealthy Normal illnesses ,bnormal 'llnesses-list. )ealth condition during adolescence# )ealthy Normal 'llnesses ,bnormal 'llnesses-/ist. )ealth Condition currently# )ealthy Normal 'llness: ,bnormal 'llness -/ist. ,ny past surgeries# ,ny accidents# -explain. No No 0es 0es: -when and what kind#.

Plea(e l!(t yo%& f!)e *a!n fea&(' 1. 2. 3. 4. 5. CIRCLE any of the follo !n" that a##ly to yo%' )eadaches ,nxiety (atigue Conflict Can7t +elax activity !i66iness (ainting &pells ,nger 'nsomnia No appetite ,lcoholism Tremors !epressed ,llergies &hyness Palpitations Nightmares (eel Tense !rug *se (eel 'nferior &tomach Trouble %owel Problems Take &edatives &uicidal 'deas !on7t like 8fun9

Can7t keep :ob ;verambitious /onely Poor memory Poor Concentration <xcessive &weating Can7t make decisions *nable to have a good time %ad )ome Conditions ;ften use aspirin or painkillers CIRCLE any of the follo !n" o&$( h!ch a##ly to yo%'

"orthless *seless 8nobody9 8/ife is empty9 'nadequate *nsafe &tupid incompetent na=ve guilty evil hostile 8cant do anything right9 morally wronghorrible thoughts full of hate ,nxious agitated cowardly unassertive panicky aggressive *gly deformed unattractive repulsive depressed lonely *nloved unconfident in conflict full of regrets worthwhile sympathetic 'ntelligent attractive confident considerate adequate safe Current interests> hobbies> activities: )ow do you spend your free time# ,ny past or current /egal Problems# -explain. ,ny current (inancial Problems# -explain. No No 0es

0es

,ny current drug or alcohol use problem# S%+(tance U(e$' Ho Often,

No

0es -include Nicotine$Caffeine.: Ho %(e$, P&o+le*,

,ny (amily )istory of !rug$,lcohol Problems# -explain.

Any "ene&al L!fe #&o+le*(, Check all that a##ly' &exual issues (amily 'ssues -explain. ,ggression toward others ,nger ?anagement problems &elf <steem ;ccupational &tress -explain. +elational Problems -other than marriage$family. @rief and$or /oss issues ;ther: ,ny Current &leep Problems# No 0es -explain.

,ny &pecific Current ,ppetite Concern# ,ny recent lifestyle changes# No 0es:

's there anything about your present behavior that you would like to change# 0es:

No

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!escribe your friends: )ow satisfied are you in your current friendships# !escribe your &pouse or Partner: )ow satisfied are you in your ?arriage$'ntimate +elationship# "hat do you see as your current strengths as a person#

"hat do you see as your general struggles#

!oes &uicide ever become an option for you#

No

0es -explain. No 0es:

,ny past or current suicidal thoughts or attempts# "hen and what happened# !oes )omicide ever become an option for you# No

0es -explain.

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,ny past or current homicidal thoughts or attempts# "hen and what happened# No 0es:

"hat do you consider your most irrational thought or fear#

)ow do you feel inside most of the time# "hat feelings do you want to alter -either increase or decrease.#

Any #a(t T&a%*a o& A+%(e $%&!n" yo%& l!fe t!*e, Physical ,buse <motional ,buse &exual ,buse: Neglect$,bandonment:

No

0es -explain.:

"hat are you willing to do to help with therapy#

"hat do you want from your counselor to help with your desired change#

'7ll know that counseling$therapy was successful when:

's there any other information that you want your counselor to know#