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LIFE HISTORY QUESTIONNAIRE

The purpose of this questionnaire is to obtain a comprehensive understanding of yourlife experience and background. Completing these questions as fully and accuratelyas possible will benefit you through the development of a treatment plan suited toyour specific needs. Please return this questionnaire on your next visit for reviewand 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 yourlife:

Check any of the follo!n" that a##l!e$ $%&!n" yo%& ch!l$hoo$'Night Terrors %edwetting &leepwalking 'rrational

(earsThumb &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# No 0es: -when and what kind#

,ny accidents# No 0es-explain

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 !i66iness (ainting &pells Palpitations &tomach Trouble,nxiety ,nger 'nsomnia Nightmares %owel Problems(atigue No appetite ,lcoholism (eel Tense Take &edativesConflict Tremors !epressed !rug *se &uicidal 'deasCan7t +elax ,llergies &hyness (eel 'nferior !on7t like 8fun9activity

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Can7t keep ob ;verambitious /onely Poor memory PoorConcentration hobbies> activities:

)ow do you spend your free time#

,ny past or current /egal Problems# No 0es-explain

,ny current (inancial Problems# No 0es-explain

,ny current drug or alcohol use problem# No 0es -include Nicotine$Caffeine:S%+(tance U(e$' Ho Often, 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

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's there anything about your present behaviorthat you would like to change#No0es:

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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

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

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

)ow do you feel inside mostof 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, No 0es -explain: Physical ,buse

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"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#