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Social History Please complete the following questions to the best of your ability and submit below. The more we understand about you, the better able we are to assist you and speed the resolution of your concerns. Thanks. Your Name: * Medical When was your last physical exam? Anything noteworthy? Are you currently taking any medications?   Yes   No If yes, what and why? How would you rate your physical health?   Excellent   Good   Fair   Poor   Very poor Briefly identify and significant current or past physical problems Have you ever been hospitalized for an emotional or mental illness or chemical dependency?   Yes   No If yes, describe Emotional History Have you ever sought professional counseling before?   Yes   No If yes, when? Why? With whom? Were you satisfied with the counseling?   Yes   No Why are you seeking counseling now? How long have you been experiencing this difficulty? The event which led me to contacting for an appointment now rather than a few days or two weeks ago was: How severe do you believe this problem is?   Just an irritant   Mildly upsetting   Moderate   Severe   Extremely severe   Totally incapacitating Family history of related issues: Do you have any blood relatives who have had any similar problems as you have now? Also, please comment on any blood relatives who have had or seem to have had any psychological or emotional problems, suicide attempts, psychiatric hospitalizations or very eccentric behavior. Issues of Safety I have had thoughts of suicide in the last few days or two weeks:   Yes   No If yes, for how long have these thoughts been there? I have a plan as to how to commit suicide:   Yes   No The plan I have: Have you ever in your life made any attempt to end your life?   Yes   No I wish that my death would happen, but I would not cause it myself:   Yes   No Family Developmental History Cities and states where I was primarily raised My parents were married only to each other:   Yes   No If no, how many times was your father married? If no, how many times was your mother married? 1) First name of mother or stepmother, length of marriage or relationship, names of children born, your age upon start of relationship 2) First name of mother or stepmother, length of marriage or relationship, names of children born, your age upon start of relationship 3) First name of mother or stepmother, length of marriage or relationship, names of children born, your age upon start of relationship 1) First name of father or stepfather, length of marriage or relationship, names of children born, your age upon start of relationship 2) First name of mother or stepmother, length of marriage or relationship, names of children born, your age upon start of relationship 3) First name of mother or stepmother, length of marriage or relationship, names of children born, your age upon start of relationship If there were divorces, how often did you have contact with the parent no longer in the home? What kind of work did your father do when you were growing up? What kind of work did your mother do when you were growing up? Was the family financially stable when you were growing up?   Yes   No How did your parents usually get along with each other? Your relationship with your father during your childhood years was:   Very close   Close   Distant   Very distant Your relationship with your father during your adolescent years was:   Very close   Close   Distant   Very distant Your relationship with your mother during your childhood years was:   Very close   Close   Distant   Very distant Your relationship with your mother during your adolescent years was:   Very close   Close   Distant   Very distant How did you usually get along with your borthers and sisters? How did you tend to get along with others your own age in grade school, junior high and high school? Please mention or describe any significant childhood experience or events that would be relevant to your sessions here. How did you feel about yourself in your youth? Current Family History Describe how you see yourself now and how you tend to get along with others: Name of spouse or significant other: Type of work he/she does? Briefly describe the quality of the marriage/relationship Have there been any separations?   Yes   No If yes, how many? If yes, when was the most recent? If yes, how long did it last? If yes, how long did other separations last? If there has been any talk between the two of you of separation or divorce, recently or in the past, please comment: Comment on the relationship between you and each of your children: Total number of times you have been married? Total number of times your spouse has been married? Name each of the people in your household now and what is your relationship with each? Name the cites and states where your parents, brothers and sisters live now, comment on whether or not you tend to get along with each, and how often you have contact: If any of your parents, brothers or sisters have died, about how long ago did it happen and what wast he cause of death? Marriage and/or Significant Boyfriends/Girlfriends 1st Spouse or significant other Name: Age: Marriage year Divorce Year Whereabouts Type of work Children, age and frequency of contact 2nd Spouse or significant other Name: Age: Marriage year Divorce Year Whereabouts: Type of work Children, age, and frequency of contact 3rd Spouse or significant other Name: Age: Marriage Year Divorce Year Whereabouts Type of Work Children, age, and frequency of contact Alcohol You drink alcohol once every: Last drink was when? What kind of alcohol do you drink? How much alcohol is usually consumed every drinking occasion? Have you ever had a DWI or DUI?   Yes   No If yes, how many? If yes, when was the last one? Have you ever attended AA meetings?   Yes   No Do you currently attend AA meetings?   Yes   No What is the longest continuous time in the past 12 months you have gone without any alcohol? Do problems in your life seem to happen as a result of your drinking?   Yes   No Not now, but in the past. How long ago? If yes, check all that apply:   in my marriage   in my family   with money management   with employment   with friends   with memory   with the law   with my health Other Drugs Have you used marijuana?   Yes   No If yes, when did you last use marijuana? If yes, you use marijuana once every: Have you ever used cocaine?   Yes   No If yes, when did you last use cocaine? Have you ever used meth amphetamines?   Yes   No If yes, when did you last use meth amphetamines? Types of other recreational or street drugs you have used in your life? Last use of drugs listed above: Do you mis-use prescription or over-the-counter medications?   Yes   No Have you ever attended any NA meetings?   Yes   No Do problems seem to happen in your life as a result of use of recreational or street drugs?   Yes   No Not now, but inthe past. How long ago? If yes, check all that apply:   in my marriage   in my family   with money management   with employment   with friends   with memory   with the law   with my health Do you have any relatives or significant relationships who have or had problems with alcohol or other drugs?   Yes   No If yes, please list and include the type of chemical used or mis-used Physical and sexual abuse Were you ever physically abused as a child?   Yes   No Were you ever sexually abused as a child by any relatives, acquaintances or strangers?   Yes   No Were you ever physically abused or assaulted as an adult?   Yes   No Were you ever sexually assaulted as an adult by any relatives, acquaintances or strangers, including dating situations?   Yes   No Education What level of education or year in school did you last complete? If you had some college or graduated, what was the school, the degree and major? Employment I am:   Employed   Retired   Unemployed and looking   Disabled   Homemaker   Student Name of employer: Length of employment there: Current job title and/or type of work there: If you are undergoing any particular undue stress on the job lately, please comment: Would you say that your work history leans more toward job stability or more toward job instability?   Stability   Instability Legal Issues Do you have any current legal problems, including upcoming court dates, issues of child support payments, pending dissolution of marriage filing? Military Have you ever been in the military service, and if so, in which branch, for how long, and what kind of discharge did you have? Religious faith Do you regularly attend church services?   Yes   No If yes, what faith or denomination? Name of church: Would you say that your faith plays an important an central role in your life these days, or that it tends to play not such an important role in your life these days?   Important   Not so important If important, please comment in what ways your faith is important in your life: Check as many as apply to your sense of spirituality   Not spiritual   Seeking   Hurt by church   Evangelical   Skeptical   Growing   I love God   Charismatic   Born again   God is unfair   New Age   Catholic   Afraid of God   Demonic   Out of God's will   Atheist   Spirit-filled   Losing my faith   Mad at God   Faithful   God is hard to please   Non-traditional   God loves me   Abandoned by God Finances Are you having any problems meeting the needs of food or keeping a roof over your head?   Yes   No Are creditors periodically contacting you about unpaid and problematic bills?   Yes   No Ballpark guess as to your total credit card debt: Do you have any debts associated with gambling?   Yes   No Activities and Interests Comment on any activities of special interest to you, what you enjoy doing with your time, and describe how a usual day goes for you: Additional comments Feel free to add any additional information you think would be helpful

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