CLIENT BACKGROUND. What problem brings you to seek counseling today? How long have you had this problem?
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- Marjory Montgomery
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1 WELLSPRING Counseling Center Dr. Sheri McCallister, DMin, MA, LPC CLIENT BACKGROUND Client Information First Name MI Last Address City State Zip Occupation Marital Status:! Single! Married! Divorced Spouse/significant other name Emergency Contact Name Relationship Address City State Zip Phone What problem brings you to seek counseling today? How long have you had this problem? Are there any other problems that seem to grow out of this one? Wellspring Counseling Center Client Background 1/10
2 What former help have you sought for this situation? Circle all that apply. Psychiatrist Prayer Christian Science Chiropractor Healing evangelist Spiritualistic healer Psychologist Social worker Counselor Pastor Medicine Priest Group therapy Hypnosis by another Self-hypnosis Other: Family How many people were in your childhood family? Who did you live with? Who were you closest to and why? What did you like to do with your family? Wellspring Counseling Center Client Background 2/10
3 How much time did you spend with them every day? Describe your parents briefly. What did your father say when he complimented you? Criticized you? What did your mother say when she complimented you? Criticized you? Describe your relationship to your spouse, your children, and your parents. Wellspring Counseling Center Client Background 3/10
4 Describe the level of communication between family members. What problems inhibit healthy relationships within your family? Important Events What is your earliest memory? What is your happiest memory? What is your saddest memory? Wellspring Counseling Center Client Background 4/10
5 Self If you could change anything about yourself, what would it be? List 5 strengths you have. List 5 weaknesses you have. How do you work on areas needing growth? What is your biggest problem? Wellspring Counseling Center Client Background 5/10
6 What is your biggest joy? Work Describe work-related experiences and their impact on you. Are you fulfilled in what you do? Why or why not? What are your plans, dreams, and visions regarding your vocation? To what degree is your identity linked to your job? Wellspring Counseling Center Client Background 6/10
7 How do you view money? How important is it to you? Spiritual Describe work-related experiences and their impact on you. Describe your parents' spiritual background. Were your parents married, divorced, or never married? Who was the head of the home: your mother, father, or other? How did your father treat your mother? Wellspring Counseling Center Client Background 7/10
8 How did your mother treat your father? Did your parents or grandparents have an affair? If so, describe briefly. Were there any incestuous relationships in your family? If so, describe briefly. Do you have any regular devotions in the Bible? When and to what extent? Do you find prayer difficult? Explain. When attending church or church-related ministries, are you plagued with foul thoughts, jealousies, or other mental harassment? Explain. Wellspring Counseling Center Client Background 8/10
9 Do you listen to music? What type do you enjoy? How much TV do you watch? What shows do you watch regularly? If you died tonight and appeared before God in heaven, and He were to ask you why you should be allowed in His presence, what would your response be? Have you been involved in any of the following? Circle all that apply. Hypnotism Ouija boards Spiritualism Levitation Christian Science Horoscopes Mormonism Blood poets Jehovah's Witness Fetishism Free Masonry Eastern Religions Eastern Star Scientology Rainbow Girls Islam Demolay Hinduism Pacts with Satan Buddhism Satanism Seances Witchcraft Astral projection Fortune telling Spirit guides Dungeons & dragons Palm reading Tarot cards Astrology Black magic White magic New Age medicine Wellspring Counseling Center Client Background 9/10
10 Please elaborate on any of the above that you circled. Do you ever have any of the following symptoms? Circle all that apply. Frequent or recurrent illness Seizures Depression Sleeplessness Supernatural power Hearing voices Anger Addictions Mood swings Fear Bizarre behavior Nightmares Please elaborate on any of the above that you circled. If there is anything else in any area of your life you would like to communicate, please describe below. Wellspring Counseling Center Client Background 10/10
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