Adult Background Questionnaire

Lauren Hutchinson

Adult Background Questionnaire
Contact Information
Name First Name   Last Name Date of Birth Date
Home Address Street Address   Address Line 2  City
Mobile Phone Phone Number E-mail Email
Occupation (title, name of company, industry)
Gender identity:

FemaleMaleNon-binary
Is your gender identity different from gender assigned at birth?

NoYes
If yes, please tell me more about about this identity change (I am an ally for gender non-conforming humans):
Please tell me more about your identity as it is important to you. This can include racial and ethnic identities, religious or spiritual identities, gender identity and expression, sexual orientation and expression, languages other than English spoken, neurodiversity, different abilities (including physical and cognitive abilities), etc. Please let me know if you have felt marginalized by these identities. I embrace and celebrate all forms of diversity in my practice.

Family Information
Select one choice that best describes your primary household:

Living alone (no partner)Living alone (separate from partner)Living with others (friends or family)Living with partner, no children in householdLiving with married partner, no children in householdLiving with partner, children in householdLiving with married partner, children in householdOther
Please list all people currently living in your household, including children and adults. If none, please enter "none" under Name.*
Please describe any major changes in your living situation or significant personal or family stresses experienced over the past two years:
e.g. major move, death of a close family member, serious illness, family conflict, unemployment, trauma
Please describe the relationship you had with parents or caregivers growing up. What do you most remember about closeness, safety, being comforted, and feeling seen and understood by these adults when you were a child and teen? How is that relationship now?

Current Concerns
What brings you to counseling? What would you most like to work on? Please be as specific as you can based on the knowledge you have of yourself.
When did you first become concerned about these issues? How have you addressed these concerns in the past?
Have you received any chronic health or psychiatric diagnoses in the past? How relevant are they at this time?
Examples might include anxiety, depression, autism, ADHD, epilepsy, arthritis, asthma, cancer, diabetes, Lyme disease, fibromyalgia, other autoimmune diseases, etc. Please list year diagnosed.
Has you been seen by other mental health service providers (medical providers will be asked about in next section)? If none, please put "none" under Name of Provider.*
What do you consider to be your greatest strengths? What do you love doing? Please include activities, sports, hobbies, enthusiasms, passions, and deep interests that you enjoy, even if you don't do them as much as you'd like. Include character strengths and what makes you a unique human!
e.g. positive personality traits, interests, athletics, creative hobbies, music, art, STEM/technology (programming, engineering), leadership, outdoors/nature, entrpreneurship, volunteerism/community service

If the work we do together has a positive outcome, what would change or be different? What struggles for you would be relieved? What does a picture of you thriving in your life look like? Is there anything else you would like me to know?

	Yes/No	Relationship of family member
Epilepsy, seizures, Tourette's
Depression/Anxiety
ADHD or attention problems
Autism or suspected autism
Dyslexia or reading problems
Substance abuse or addiction

Lauren Hutchinson