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Life History
(ages 14 & older)
CONFIDENTIAL
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Name of therapist you are scheduled with:
*
Unknown
Other
Client Details
Client Full Name:
*
First Name
Middle Initial
Last Name
Client Preferred Name:
Client Birthdate:
-
Month
-
Day
Year
Date
Best Phone Number:
*
This is a Parent/Guardian Phone #
Email Address:
*
This is a Parent/Guardian Email
Last education level completed:
*
Occupation:
*
Client Employment:
*
Employed
Unemployed
Full-Time Student
Part-Time Student
Retired
Disabled
Client Employer:
If enrolled in school, please indicate grade level and school/college currently attending
Client Marital Status
*
Single
Engaged
Married
Widowed
Divorced
Separated
Common Law
Living Together
Significant Other Name
First Name
Last Name
Significant Other Date of Birth:
/
Month
/
Day
Year
Significant Other Phone Number:
Significant Other Email Address:
Name, Current Age, and Birth Date of your Children:
Do you practice a religion/faith?
*
Yes
No
If yes, what is your faith?
Please indicate faith
Adolescent clients
#1 Parent/Guardian Name
First Name
Last Name
#2 Parent/Guardian Name
First Name
Last Name
Indicate Relationship Status of Parents/Guardians:
Indicate Custody Agreement
List Name of Person Responsible for Child's Account:
List others who live in the home? (Mom, dad, siblings, grandparents, etc.)
Physical Health Information
Primary Physician Name:
Primary Physician Phone Number
Primary Physician Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
How would you rate your overall health at present time
Please Select
Poor
Unsatisfactory
Satisfactory
Good
Very Good
Date of Last Physical:
/
Month
/
Day
Year
Please list any persistent physical symptom or health concern (e.g. chronic pain, diabetes, headaches, etc.) :
Current Medical Diagnoses:
List current prescribed and OTC medications and dosage:
Are you having any difficulties with your sleep habits?
Yes
No
If yes, click all that apply
Sleep too much
Sleep too little
Poor quality
Disturbing dreams
Other
Are you having any difficulties with your eating habits?
Yes
No
If yes, click all that apply
Eating less than usual
Eating more than usual
Binging
Restricting
Other
How many times per week do you generally exercise?
What type of exercise do you participate in?
Mental Health Information
Have you had any suicidal thoughts recently?
Yes
No
If yes, how often?
Please Select
Frequently
Sometimes
Rarely
Have you had any suicidal thoughts in the past?
Yes
No
If yes, how long ago?
Check all that apply below:
I have previously been involved in counseling
I have been hospitalized for mental health reasons
I have previously been in legal trouble
There is a history of alcohol or drug problems in my family
There is a history of mental health problems in my family
Please check any symptom you have experienced and indicate the severity of your concern. (No Concern, Mildly Concerned, Moderately Concerned, or Highly Concerned)
N/A
Current
Past
No Concern
Mildly Concerned
Moderately Concerned
Highly Concerned
Restlessness
Racing thoughts
Mood swings
Concentration problems
Depression
Anxiety/Worry
Panic attacks
Phobias
Anger issues
Impulsive behaviors
Feeling the need to repeat things
Obsessive/repetitive thoughts
Food/Eating problems
Sleep issues
Frequent nightmares
Self-harming behaviors
Drug use
Nicotine/vape use
Alcohol use
Sex problems
Hearing voices others do not hear
Seeing things others do not see
Relationship problems
Family conflict
Physical abuse
Sexual abuse
Emotional/verbal abuse
Any other concerns?
Current Reason for Seeking Therapy
*
How long has the problem that you are coming in for persisted?
Under what conditions do your problems get worse? Better?
How serious do you consider your present concerns?
Not at all
Mildly
Moderately
Highly
How motivated are you to resolve your concerns?
Not at all
Mildly
Moderately
Highly
How optimistic are you that your concerns can be resolved?
Not at all
Mildly
Moderately
Highly
Family History
Mother's age:
If deceased, how old were you when your mother died?
Father's age:
If deceased, how old were you when your father died?
If your parents separated, how old were you when they separated?
Number of brothers and their ages?
Number of sisters and their ages?
If you were adopted or raised with parents other than your natural parents, please explain:
Briefly describe your mother's personality, along with your past and current relationships:
Briefly describe your father's personality, along with your past and current relationships:
If relevant, briefly describe your step-mother's personality, along with your past and current relationships:
If relevant, briefly describe your step-father's personality, along with your past and current relationships:
Please fill out the following questionnaire if you are 18 years old or older.
Adverse Childhood Experience (ACE) Questionnaire
While you were growing up, during your first 18 years of life:
Did a parent or other adult in the household often, or very often, swear at you, insult you, put you down, or humiliate you? Or act in a way that made you afraid that you might be physically hurt?
No
Yes
Did a parent or other adult in the household often, or very often, push, grab, slap, or throw something at you? Or ever hit you so hard that you had marks, or were injured?
No
Yes
Did an adult or person at least five years older than you ever touch or fondle you, or attempt, or have you, touch their body in a sexual way? Or attempt, or actually have oral, anal, or vaginal sex with you?
No
Yes
Did you often, or very often, feel that no one in your family loved you or thought you were important or special? Or did your family not look out for each other, feel close to each other, or support each other?
No
Yes
Did you often, or very often, feel that you didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? Or were your parents too drunk, or high, to take care of you or take you to the doctor, if you needed it?
No
Yes
Were your parents ever separated or divorced?
No
Yes
Was your mother or step mother often, or very often, pushed, grabbed, slapped, or had something thrown at her? Or sometimes or often kicked, bitten, hit with a fist, or with something hard? Or repeatedly hit over at least a few minutes or threatened with a gun or knife?
No
Yes
Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
No
Yes
Was a household member depressed, or mentally ill, or did a household member attempt suicide?
No
Yes
Did a household member go to prison?
No
Yes
SUBMIT LIFE HISTORY ADULT
Should be Empty: