LIFE HISTORY QUESTIONNAIRE

The purpose of this questionnaire is to obtain a comprehensive understanding of your life experience and background. Completing these questions as fully and accurately as possible will benefit you through the development of a treatment plan suited to your specific needs. Please return this questionnaire on your next visit for review and discussion.

PLEASE COMPLETELY FILL OUT THE FOLLOWING PAGES

Name:______Date:______

What do you want to gain from counseling? ______

What is the role of religion and/or spirituality in your life:______

______

Check any of the following that applied during your childhood:

___Night Terrors___Bedwetting___Sleepwalking___Irrational Fears

___Thumb Sucking___Nail Biting___Nervous Behavior___Hair Pulling

___Happy Childhood___Unhappy Childhood___Rational Fears___Aggression

What was your health condition during childhood?

___Healthy___Normal illnesses

___Abnormal Illnesses(list)______

Health condition during adolescence?

___Healthy___Normal Illnesses

___Abnormal Illnesses(List) ______

Health Condition currently?

___Healthy___Normal Illness:______

___Abnormal Illness (List)______

Any past surgeries? ___ No ___ Yes: (when and what kind?) ______

Any accidents? ___ No ___ Yes (explain)______

Please list your five main fears:

  1. ______
  2. ______
  3. ______
  4. ______
  5. ______

CIRCLEany of the following that apply to you:

HeadachesDizzinessFainting SpellsPalpitationsStomach Trouble

AnxietyAngerInsomniaNightmaresBowel Problems

FatigueNo appetiteAlcoholismFeel TenseTake Sedatives

ConflictTremorsDepressedDrug UseSuicidal Ideas

Can’t RelaxAllergiesShynessFeel InferiorDon’t like “fun” activity

Can’t keep jobOverambitiousLonelyPoor memoryPoor Concentration

Excessive SweatingCan’t make decisionsUnable to have a good time

Bad Home ConditionsOften use aspirin or painkillers

CIRCLE any of the following words which apply to you:

WorthlessUseless“nobody”“Life is empty” InadequateUnsafe

Stupidincompetentnaïveguiltyevilhostile

“cant do anything right”morally wronghorrible thoughtsfull of hate

Anxiousagitatedcowardlyunassertivepanickyaggressive

Uglydeformedunattractiverepulsivedepressedlonely

Unlovedunconfidentin conflictfull of regretsworthwhilesympathetic

Intelligentattractiveconfidentconsiderateadequatesafe

Current interests, hobbies, activities: ______

______

How do you spend your free time?______

______

Any past or current Legal Problems? ___ No ___Yes (explain)______

______

Any current Financial Problems? ___ No ___ Yes (explain)______

______

Any current drug or alcohol use problem? ___ No ___ Yes (include Nicotine/Caffeine):

Substance Used:How Often?How used?Problem?

______

______

______

Any Family History of Drug/Alcohol Problems? (explain) ______

______

Any general Life problems? Check all that apply:

___ Sexual issues___ Family Issues (explain)______

___ Aggression toward others___Anger Management problems___ Self Esteem

___ Occupational Stress (explain)______

___ Relational Problems (other than marriage/family)___ Grief and/or Loss issues

___ Other:______

Any Current Sleep Problems? ___ No ___Yes (explain)______

Any Specific Current Appetite Concern?______

Any recent lifestyle changes? ___ No ___ Yes:______

______

Is there anything about your present behavior that you would like to change?___No ___Yes:

______

______

Describe your friends: ______

______

How satisfied are you in your current friendships?______

Describe your Spouse or Partner: ______

______

How satisfied are you in your Marriage/Intimate Relationship? ______

What do you see as your current strengths as a person?______

______

What do you see as your general struggles?______

______

Does Suicide ever become an option for you? ___No ___Yes (explain)______

______

Any past or current suicidal thoughts or attempts? ___No ___ Yes:

When and what happened?______

______

______

Does Homicide ever become an option for you? ___No ___Yes (explain)______

______

Any past or current homicidal thoughts or attempts? ___No ___ Yes:

When and what happened?______

______

______

What do you consider your most irrational thought or fear? ______

______

How do you feel inside mostof the time? ______

What feelings do you want to alter (either increase or decrease)? ______

______

Any past Trauma or Abuse during your life time?___ No ___ Yes (explain):

___ Physical Abuse ______

___ Emotional Abuse______

___ Sexual Abuse:______

___ Neglect/Abandonment: ______

What are you willing to do to help with therapy? ______

______

What do you want from your counselor to help with your desired change?______

______

I’ll know that counseling/therapy was successful when:______

______

Is there any other information that you want your counselor to know? ______

______

______

______