Name
Sex
Age
Date of Birth
Address
Phone
Occupation
Education/Training
Business Address and Phone
Referred for counseling by
Personal History
Parents/Guardian:
Name Age (if living) Occupation Marital Status
Siblings:
Name Age Relationship Marital Status
Indicate which might have applied during your childhood and/or adolescence:
Has anyone in your immediate family been hospitalized or received some form of professional help for psychological problems? If so, please specify who, when they received help, and the nature of the problem.
Occupational History
What positions have you held in the past?
Does your present work satisfy you? If not, please explain
Present annual income
Marital History
Marital Status:
Your present marriage (if applicable):
Spouse's name Age Occupation Religious Background Education Date of Marriage
Have you ever been separated from your present spouse? (If yes, please specify when)
Children
Name Relationship (Son, step-daughter, etc) Living at home Age Marital Status Occupation
Your previous marriages (include dates and children from the marriage)
Spouse's previous marriages (include dates and children from the marriage)
Religious Background
Denominational preference
Church presently attended (name, address, & phone)
Pastor
Permission to consult with pastor
Do you believe in God?
Do you consider yourself "saved"?
If you were to die and stand before God and He asked you why He should permit you to enter heaven, how might you respond?
Medical History
Have you had any of the following physical problems?
List previous surgeries (those which required anesthesia)
List all prescription and over the counter medications. Include diet pills, laxatives, birth control pills, cold and allergy medicines, aspirin.
What is your average daily caffeine consumption? Include coffee, tea, chocolate, stimulants, and caffeinated soft drinks.
How many hours of sleep do you average each night? Have there been any recent changes? Is this sleep restful?
Have you or others noticed any changes in your personality (anger, mood swings, withdrawal), thinking and memory, or work habits)?
Main Problem(s)
State in your own words the nature of the main problem(s) :
When did your problems begin? Please specify a date if possible.
Please describe any significant events occurring at that time.
First Name: *
Email: *
Website:
