Life, Family and Relationship Questionnaire

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Date of Initial Session: Client Name Date of Birth Address City Zip Phone Number Email Emergency Contact Relationship Emergency Contact Ph. # Client Name: Date: Life, Family and Relationship Questionnaire Partner/Spouse Name Date of Birth Address The purpose (If Different) of this questionnaire is to help me get an idea of City who you are and your State life s journey Zip to this point. By asking these questions now, we can save valuable time. Please answer these questions as fully and Phone Number accurately as you can. It will make it possible for us to get right to work on the topics that are most important to you. 1

All responses are confidential and will not be released without your written permission. If you have any questions, please feel free to ask. Age: Relationship Status: Single Dating Living Together Engaged Married Separated Divorced Widowed Partner s Name: Age: Length of Partnership: Previously Married: Yes No (If yes, how many times? ) Partner Previously Married: Yes No (If yes, how many times? ) Number of Children: Reason for Seeking Counseling My reason(s) for seeking counseling is/are: What solutions to your concern(s) have you found helpful? When did the concern(s) begin? _ Other concerns I have include: Feeling blue Low self-esteem Feeling angry Anxious Family tension/conflict Religious differences Parenting concern Addiction concerns Financial stress Tired Sexual difficulties Work stress Infidelity concerns Eating problems Lack of trust Communication Issues Custody/visitation Other: Other: Other: 2

If you checked Other, please tell me more: I am Experiencing Never Seldom Often Always For how long? Frequent worry or tension Fear of many things Discomfort in social situations Feelings of guilt Phobias Panic attacks Recurring, distressing thoughts about a trauma Flashbacks as if reliving the trauma Nightmares about traumatic experience I am Feeling Never Seldom Often Always For how long? Less interest in pleasurable activities Social isolation, loneliness Suicidal thoughts Bereavement of feelings of loss Changes in sleep (too much or not enough) Normal daily tasks require more effort Sad, hopeless about future Excessive feelings of guilt Low self-esteem 3

I have Never Seldom Often Always For how long? Memory problems or trouble concentrating Trouble explaining myself to others Problems understanding what others tell me Intrusive or strange thoughts Obsessive thoughts Been hearing voice when alone Problems with my speech I have Never Seldom Often Always For how long? Risk taking behaviors Compulsive or repetitive behaviors Been acting without caring about the consequences Been physically harming myself Been violent toward others I am noticing Never Seldom Often Always For how long? I am angry, irritable, hostile I feel euphoric, energize and very optimistic I have racing thoughts I need less sleep than usual I am more talkative My moods fluctuate: go up and down 4

Health Do you have any physical symptoms that concern you? List any medications you are taking: Family Doctor: Date of last physical How often do you exercise? Do you: (Check all that apply) Drink alcohol Have trouble sleeping Smoke Drink caffeine Want to (gain/lose) weight Have high blood pressure Have allergies Other: Use recreational drugs Other: Other: Briefly describe your overall health My eating involves Never Seldom Often Always For how long? Restriction of food eaten Bingeing and purging Binge eating A lot of weight loss or gain Thinking about food constantly Working out a lot to burn off food I ate 5

Personal and Family History Have you ever been hospitalized for a mental health concern? Yes No When and where? Has a close relative ever been hospitalized for a mental health concern? Yes No Relative: Does anyone in your family have a mental illness? Yes No Which illnesses? Has anyone in your family ever attempted or committed suicide? Yes No Who? Does anyone in your family have a substance abuse problem? Yes No Who? How well are 0 1 2 3 4 5 6 7 8 9 you. Not Cannot Serious Moderate Mild No Working/NA Function Problems Problem Problems Problems Doing on your job Doing in your marital/partner relationship Doing in your family relationships Doing in relationships with people outside your family Doing with your 6

physical health Doing with your general happiness and well-being History of Professional Help Have you ever had professional mental health assistance? Yes No If yes, what type of professional(s)? For you, counseling will be successful when: Please answer the following questions (Circle your answer): 1. I think that counseling will be helpful. Strongly disagree Disagree Neutral/Indifferent Agree Strongly Agree 2. I think that I deserve to live a good life. Strongly disagree Disagree Neutral/Indifferent Agree Strongly Agree 3. I am able to create the change I wish to see. Strongly disagree Disagree Neutral/Indifferent Agree Strongly Agree 7

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