LIFE HISTORY QUESTIONNAIRE

The purpose of this questionnaire is to obtain a comprehensive picture of your background. By completing these questions, as fully and as accurately as you can, you will provide your therapist with important information, without using your actual therapy time. Please answer these questions on your own time. The information in this questionnaire will be kept by your therapist and will not be disclosed to anyone without your written permission. Case records are strictly confidential. If you do not wish to answer a question simply write, Do not care to answer.

THERAPIST'S NAME

CLIENT'S NAME

AGE

OCCUPATION

By whom were you referred?

Who presently lives with you?

MARITAL STATUS

How many times

Single, Engaged, Married, Separated, Divorced, Widowed

Do you live in a house, hotel, room, apartment, etc.?

CLINICAL

1 State in your own words the nature of your main problems and their duration

2 Give a brief account of the history and development of your complaints (from onset to present)

4 With whom have you previously consulted about your present problem(s)?

3 On the scale below please estimate the severity of your problems: Mildly Upsetting Moderately Severe Very Severe Extremely Severe Totally Incapacitating

1 What sort of work are you doing now?

2 What sort of work have you done in the past?

3 Does your present work satisfy you? (If not, in what ways are you dissatisfied?)

4 Ambitions

Past

Present

1 Parental attitudes to sex (i.e., was there sex instruction or discussion in the home)?

2 When and how old were you when you derived your first knowledge of sex?

3 When did you first become aware of your own sexual impulses?

4 Have you ever experienced any anxiety or guilt feelings arising out of sex or masturbation? If "yes," please explain.

5 put down any of the following words which apply to you:worthless, useless, "nobody," "life is empty," inadequate, stupid, incompetent, naïve, "can't do anything right," guilty, evil, morally wrong, horrible thoughts, hostile, full of hate, anxious, agitated, cowardly, unassertive, panicky, aggressive, ugly, deformed, unattractive, depressed, unloved, misunderstood, bored, restless, confused, unconfident, in conflict,full of regrets, worthwhile, sympathetic, intelligent, attractive, confident, considerate, assertive

1 Present interest, hobbies and activities

2 How is most of your free time occupied?

3 What is the last grade of school you completed?

4 Scholastic abilities; strengths and weaknesses

5 Were you ever bullied, severely bullied or severely teased?

6 Do you make friends easily? If so, do you keep them?

7 List five main fears:

1

2

3

4

5

8 List any of the following that apply to you. headaches, financial problems, fainting, palpitations, dizziness, no appetite, bowel disturbances, stomach trouble, insomnia, nightmares, fatigue, alcoholism, feel tense, take sedatives, tremors, unable to relax, suicidal ideas, shy with people, depressed, feel panicky, take drugs, don't like weekends, sexual problems, can't make decisions, don't like vacations, can't make friends, over rambunctious, can't keep a job, disoriented, unable to have a good time, concentration difficulties, memory problems

1 In what areas of the family is there compatibility?

2 In what areas is there incompatibility?

3 How do you get along with your in laws? (this includes brothers/sisters in law)

4 How many children do you have? Please list their sex and age.

5 Do any of your children present special problems?

6 Give details of any previous marriage(s

Living or deceased?

If deceased, your age at the time of his death?

Cause of death?

If alive, father's present age?

Occupation?

Health?

Mother

If deceased, your age at the time of her death?

Cause of death?

If alive, mother's present age?

Occupation?

Health?

8 As a child in what ways were you punished by your parents?

9 Give an impression of your home atmosphere (i.e., the home in which you grew up Mention state of compatibility between parents and between parents and children.

10 Were you able to confide in your parents?

11 If you have a stepparent, what was your age when your parent remarried?

12 Give a description of your religious training.

13 If you were not brought up by your parents, who brought you up, and between what years?

14 Has anyone (parents, relatives, friends) ever interfered in your marriage, occupation, etc.?

15 Who are the most important people in your life?

Please complete the following:

I am

I feel

I think

I wish

Have my therapist respond to me on a person-to-person basis.

Get advice on how to deal with my life and with other people.

Get better self-control.

Get clarity regarding which things I think and feel are real and which things are mostly in my mind.

Work out a particular problem that's been bothering me.

Get my therapist to say what he/she really thinks.

LIFE HISTORY QUESTIONNAIRE

OCCUPATIONAL:

SEXUAL HISTORY:

OTHER AREAS:

FAMILY DATA:

SELF-DESCRIPTION:

I would like to : Please indicate NON, SOME, ALOT