QUESTIONNAIRE

The purpose of this questionnaire is to obtain a comprehensive understanding of your life experience and background. The information you provide is strictly confidential. Please complete this questionnaire as thoroughly as possible. This questionnaire will assist us in the process of identifying your concerns and your goals for therapy. If any portion of this questionnaire is confusing or difficult to complete please discuss this with your therapist.


























FAMILY CHART
  NAME AGE SEX LIVING OR
DECEASED
MARITAL
STATUS
OCCUPATION TOWN & STATE
SPOUSE
CHILDREN
 
 
 
 
 
 
FATHER
MOTHER
SIBLINGS
 
 
 
 
 
OTHERS
STEP-SIBLINGS
EX-SPOUSE
ETC.
FAMILY HISTORY







For the members of your family listed on the chart















PARENTS



INDIVIDUAL PAST HISTORY



If yes, describe











MEDICAL














SCHOOL HISTORY














SELF-DESCRIPTION
(Please complete the following)


















Give a brief description of yourself by the following people




List your five main fears





SEXUAL HISTORY (ALL)










SEXUAL HISTORY (WOMEN)

















MARITAL HISTORY












OCCUPATIONAL HISTORY








RELIGION



Role of religion and/or spirituality in your life


Parents' religion:


HOBBIES





ALCOHOL AND/OR DRUG USE








LAW VIOLATION


CURRENT PROBLEMSClick here to enter a heading





The problems I want to work on in therapy are
















Thank you for completing this questionnaire.