Biographical Information Form
Non-binary / third gender
Prefer to self-describe upon meeting
Present relationship status (check all that apply):
In a new relationship (6 months or less)
Dating one person
Dating several people
In a long term relationship
Are you presently receiving other counseling services?
If yes, please describe:
Have you received counseling in the past?
If yes, what was most helpful about the previous therapist? What was unhelpful?
Are the issues that brought you to your previous therapist persisting? If so, how long has this/these problem/s persisted?
What is the main reason for coming to counseling now?
Under what conditions do your problems usually get worse?
Under what conditions are your problems usually improved?
How did you hear about my practice?
Word of Mouth
Have you ever been hospitalized for a mental health issue or spent time as a patient at a mental health clinic? If yes, please explain:
Have you ever had suicidal thoughts?
Have you ever attempted suicide?
List any major illnesses and / or operations you have had:
List any physical concerns you are currently experiencing (e.g. high blood pressure, headaches, etc):
List any physical concerns you have experience in the past:
On average, how many hours of sleep do you get per day?
Do you have trouble falling asleep at night?
Have you gained or lost over ten pounds in the past year?
What medications are you taking presently and for what purpose?
Have you ever (past or present) been dependent upon or addicted to any substance / drug / alcohol for any period of time? If yes, please explain:
Have you ever (past or present) had disordered eating of any kind (over-eating; anorexia; bulimia; purging' dependence on laxatives, etc.)? If yes, please explain:
Have you ever (past or present) suffered with body image issues?
Is anyone in your family or close friend circle struggling with addictions or an eating disorder or violence that may be having an effect on your mental health?
What is your present religious affiliation?
How Important is religious commitment to you? (1= unimportant & 10= extremely important)
Do you desire having your religious beliefs and values incorporated into the counseling process?
What is your mothers age? If deceased, how old were you when she died?
What is your fathers age? If deceased, how old were you when he died?
Any other significant parent(s) / caretakers age(s)? If deceased, how old were you when this person(s) died?
If your parents are separated or divorced, how old were you then?
Number of brothers & their ages:
Number of sisters & their ages:
You were ____ child number in the family of ____ children:
Were you adopted or raised with parents other than your biological parents?
Describe your relationship with your siblings:
Which of the following best describes THE FAMILY in which you grew up? (1= Warm/Accepting & 10= Hostile/Fighting)
Which of these best describes the way in which your family raised you? (1= Allowed me to be very independent & 10= Attempted to control me)
Describe your mother:
How did you discipline you?
How did she reward you?
How much time did she spend with you when you were a child?
Your mothers employment when you were a child:
Worked outside part-time
Worked outside full-time
How did you get along with your mother when you were a child?
How do you get along with your mother now?
Did your mother have any problems (e.g. alcoholism, violence, mental health issues, etc) which may have affected your childhood development? If yes, please describe:
Is there anything unusual about your relationship with your mother? If yes, please describe:
Describe your father / other primary parent:
How did he discipline you?
How did he reward you?
How much time did he spend with you when you were a child?
Your fathers employment when you were a child?
Worked outside part-time
Worked outside full-time
How did you get along with your father when you were a child?
How do you get along with your father now?
Did your father have any problems (e.g. alcoholism, violence, mental health issues, etc) which may have affected your childhood development? If yes, please describe:
Is there anything unusual about your relationship with your father? If yes, please describe:
Please mark how often the following thoughts occur to you:
Life is hopeless
I am lonely
No one cares about me
I am a failure
Most people don't like me
I want to die
I want to hurt someone
I am so stupid
I am going crazy
I can't concentrate
I am so depressed
God is disappointed in me
I can't be forgiven
Why am I so different?
I can't do anything right
People hear my thoughts
I have no emotions
Someone is watching me
I hear voices in my head
I am out of control
Please comment on EACH item above that you marked "frequently":
Check any behaviors and symptoms you have that occur more often than you would like:
High blood pressure
Phobias / fears
List your five greatest strengths:
List your five greatest weaknesses:
List your main social difficulties:
List your main love and sex difficulties:
List your main difficulties at school or work:
List your main difficulties at home:
List your behaviors that you would like to change:
List any additional information you believe would be helpful:
Should be Empty:
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