GENERAL INFORMATION:
Name ______________ Phone ______________
Address ______________
Occupation ______________ Business Phone ______________
Sex ______________ Height ______________
Birth Date ______________ Age ______________
Marital Status: Single _____ Going Steady _____ Married _____
Separated _____ Divorced _____ Widowed _____
Education (last year completed): _____ (grade)
Other training (list type and years completed) ______________
Referred here by ______________
Address ______________
HEALTH INFORMATION:
Rate your health (check): Very Good _____ Good _____ Average _____
Declining _____ Other _____
Your approximate weight (lbs.) ______________
Weight changes recently: Lost _____ Gained _____
List all important present or past illnesses or injuries or handicaps:
Date of last medical examination _____ Reports ______________
Your Physician ______________ Address ______________
Are you presently taking any medication? Yes _____ No _____
What? ______________
Have you used drugs for other than medical purposes? Yes _____ No _____
What? ______________
Have you ever had a severe emotional upset? Yes _____ No _____
What? ______________
Have you ever been arrested? Yes _____ No _____
Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports? Yes _____ No _____
Have you recently suffered the loss of someone who was close to you?
Yes _____ No _____
Explain ______________
Have you recently suffered loss from serious social, business, or other reversals? Yes _____ No _____
Explain ______________
RELIGIOUS INFORMATION
Denominational preference ______________ Member ______________
Church attendance per month (circle): 1 2 3 4 5 6 7 8 9 10+
Church attended in childhood? ______________
Baptized? Yes _____ No _____
Religious background of spouse (if married) ______________
Do you consider yourself a religious person? Yes _____ No _____ Uncertain _____
Do you believe in God? Yes _____ No _____ Uncertain _____
Do you pray to God? Never _____ Occasionally _____ Often _____
Are you saved? Yes _____ No _____ Not sure what you mean _____
How much do you read the Bible? Never _____ Occasionally _____ Often_____
Do you have regular family devotions? Yes _____ No _____
Explain recent changes in your life, if any.
PERSONALITY INFORMATION
Have you ever had any psychotherapy or counseling before? Yes _____
No _____ If yes, list counselor or therapist and dates.
What was the outcome? ______________
Check any of the following words which best describe you now:
active _____ ambitious _____ self-confident _____ persistent _____
nervous _____ hardworking _____ impatient _____ impulsive _____
moody _____ often-blue _____ excitable _____ imaginative _____
calm _____ serious _____ easy-going _____ shy _____
good-natured _____ introvert _____ extrovert _____ likable _____
leader _____ quiet _____ hard-boiled _____ submissive _____
lonely _____ self-conscious _____ sensitive _____ other _____
Have you ever felt people were watching you? Yes _____ No _____
Do people’s faces ever seem disoriented? Yes _____ No _____
Do you ever have difficulty distinguishing faces? Yes _____ No _____
Do colors ever seem too bright? _____ Too dull? _____
Are you sometimes unable to judge distance? Yes _____ No _____
Have you ever had hallucinations? Yes _____ No _____
Are you afraid of being in a car? Yes _____ No _____
Is your hearing exceptionally good? Yes _____ No _____
Do you have problems sleeping? Yes _____ No _____
MARRIAGE AND FAMILY INFORMATION
Name of spouse ______________ Phone ______________
Address ______________
Occupation ______________ Business phone ______________
Your spouse’s age _____ Education (in years) _____
Religion ______________
Is spouse willing to come for counseling? Yes _____ No _____ Uncertain _____
Have you ever been separated? Yes _____ No _____ When? _____
Date of marriage ______________
Your ages when married Husband ______________ Wife ______________
How long did you know your spouse before marriage? ______________
Length of steady dating with spouse ______________
Length of engagement ______________
Give brief information about any previous marriages.
Information about children:
| PM* Name | Age | Sex | Living Y or N | Education in years | Marital status |
*Check this column if child is by previous marriage (PM).
If you were reared by anyone other than your own parents, briefly explain:
How many older brothers _____ sisters _____ do you have?
How many younger brothers _____ sisters _____ do you have?
BRIEFLY ANSWER THE FOLLOWING QUESTIONS:
1. What is your problem?
2. What have you done about it?
3. What can we do? (What are your expectations in coming here?)
4. As you see yourself, what kind of person are you? Describe yourself.
5. What, if anything, do you fear?
6. Is there any other information we should know?