Life History

Life History - The Peacemaker Center

CONFIDENTIAL
Client Details
Client Full Name *

First Name Middle Initial Last Name
Client Preferred Name
If the client is under age 14, enter Parent/Guardian Name:

First Name Last Name
Client Address *

Street Address

Street Address Line 2

City State

Zip Code
Client Birth date: *

Month Day Year
Current Age: *
Gender: *

Male Female
Best Phone Number: *
This is a Parent/Guardian Phone #
Email Address: *
This is a Parent/Guardian Email
When contacted, do not mention The Peacemaker Center name Do not contact by phone number Do not contact by text message Do not contact by email
Client last education level completed: *
Client Employment: *

Employed Unemployed Full-Time Student Part-Time Student Retired Disabled
Client Employer:
Client Marital Status *

Single Engaged Married Widowed Divorced Separated Common Law Living Together
Name, Current Age, and Birth Date of your Children:
Household Member Information
Name

First Name Last Name
Date of Birth:

Month Day Year
Relationship to Client

Engaged Married Common Law Living Together
Email Address:
Phone Number:
Emergency Contact
Emergency Contact Name *

First Name Middle Initial Last Name
Emergency Contact Phone Number *
Emergency Contact Relationship to Client *
Other Information
Brief Description of Concerns to be Addressed in Therapy *
Which therapist are you scheduled with? *

Unknown
Which location are you scheduled in? *

Telehealth In-Person Downingtown West Chester Kennett Square Audubon Ft Washington
How did you hear about us? *

Friend Family Church Internet
Details on how you heard about us:
For Grant Purposes indicate Race: *

Asian Black/African American Hispanic/Latino Multiracial White/Caucasian
We welcome people of all faiths, or no faith, without judgment or pressure. Would you like your faith included in your therapy? *

Yes No Unsure
For Grant Purposes indicate Total Household Income Range: *

$0.00-$20,999.99 $21,000.00-$25,999.99 $26,000.00-$30,999.99 $31,000.00-$35,999.99 $36,000.00-$40,999.99 $41,000.00-$45,999.99 $46,000.00-$50,999.99 $51,000.00-$55,999.99 $56,000.00-$60,999.99 $61,000.00-$65,999.99 $66,000.00-$70,999.99 $71,000.00-$75,999.99 $76,000.00-$80,999.99 $81,000.00-$85,999.99 $86,000.00-$90,999.99 $91,000.00-$95,999.99 $96,000.00-$100,999.99 $101,000.00-$105,999.99 $106,000.00-$110,999.99 $111,000.00-$115,999.99 $116,000.00-$120,999.99 $121,000.00-$125,999.99 $126,000.00-$6,000,000.00
Physical Health Information
Primary Physician:
Primary Physician Phone Number
Primary Physician Address

Street Address

Street Address Line 2

City State

Zip Code
Date of Last Physical:

Month Day Year
Thyroid Level Checked

No Yes
Does Client have any self-declared chronic illnesses and/or disabilities:
Current Medical Diagnoses:
List current prescribed and OTC medications and dosage:
Mental Health Information
Check all that apply below:

I have previously been involved in counseling I currently use alcohol or non-prescription drugs There is a history of alcohol or drug problems in my family There is a history of mental health problems in my family I have been physically abused I have been emotionally abused I have been sexually abused or assaulted My concerns are interfering with my work performance My concerns are interfering with my family life I have attempted suicide I have been hospitalized for mental health reasons I have previously been in legal trouble
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 sepatated?
Number of brothers?
What are their ages?
Number of sisters?
What are their ages?
If you were adopted or raised with parents other than your natural parents, please explain:
Briefly describe your mother's personality:
Briefly describe your father's personality:
Briefly describe your step mother's personality:
Briefly describe your step father's personality:
Briefly describe your past and current relationship with your mother:
Briefly describe your past and current relationship with your father:
Briefly describe your past and current relationship with your stepmother:
Briefly describe your past and current relationship with your stepfather:
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
Should be Empty:

Client Details

Household Member Information

Emergency Contact

Other Information

Physical Health Information

Mental Health Information

Family History

Adverse Childhood Experience (ACE) Questionnaire