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Life History
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
Please Select
Alabama
Alaska
Arizona
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California
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Connecticut
Delaware
District of Columbia
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Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
SUBMIT LIFE HISTORY
Should be Empty: