Personal Information Questionnaire

PERSONAL INFORMATION QUESTIONNAIRE

Adult Form

Date: ______Name: ______

Address: ______Birth date: ______Age: ______

______Birthplace: ______Sex: ______

Social Security #: ______

OK to send mail? Yes: ______No: ______Phone: Home/cell: ______

OK to leave messages? Yes: ______No: ______Work: ______

In case of emergency contact: Name: ______Phone: ______

Address: ______Relationship: ______

Describe your reasons for seeking therapy at this time: ______

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Who referred you here?: ______

OK to thank this person/agency?: _____ Yes _____ No

History of previous counseling:

Therapist/Agency Dates Issues Outcome

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Occupation: ______Employer: ______

Length employed in current position: ______Average hours worked per week: ______

Years of schooling: ______Currently enrolled at: ______Degrees held: ______

Marital status: ______Number/dates of marriage(s): ______

Name/age/occupation of current spouse: ______

Divorce/separation dates: ______Date of any spouse death: ______

Children’s Names Birth date Gender Living where?

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List all members of your current household: ______

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Page 2

Father’s occupation: ______Birth date: ______Date of death: ______

Mother’s occupation: ______Birth date: ______Date of death: ______

Parents’ marital status: ______Remarriages: ______

Siblings’ Names Birth date Gender Living where?

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Has anyone in your immediate family (parents, siblings, spouse, children) received psychotherapy? If yes, list who, when and why:

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Religious affiliation: ______Attendance frequency: ______

Hobbies/interests/talents: ______

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Your physician: ______Last visit: ______

What prescribed and/or over-the-counter medications are you taking? (include vitamins, homeopathic/”natural” remedies and dosages): ______

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List any allergies: ______

List any physical development (including sexual) concerns: ______

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Describe your general health: ______

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Describe your sleep patterns: ______

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Describe your appetite/eating patterns: ______

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Describe your exercise program: ______

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Page 3

List any injuries, accidents, surgeries and/or other medical incidents: ______

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List any medical conditions, as well as medical conditions of immediate family members:

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Describe your past/current drug use/abuse history (include caffeine/smoking/alcohol/prescription and illegal drugs): ______

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Do you currently have any thoughts of suicide?: Yes: ______No: ______

Describe any past suicide attempts/hospitalizations: ______

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Check all items that apply to you:

______Job-related concerns ______Obsessions/compulsions

______Family violence (threat/actual) ______Financial concerns

______Suicidal thoughts ______Family issues

______Sleeping problems ______Suicidal actions

______Sexual abuse ______Eating problems

______Alcohol/drug abuse ______Physical abuse

______Grief/Loss ______HIV positive/AIDS

______Age transition issues ______Self-esteem

______Parent-child conflict ______Depression

______Panic attacks ______Relationship issues

______Health concerns ______Legal difficulties

______Anxiety/stress ______Sexual issues

______Separation/divorce ______Confusion about life goals

______Hallucinations ______Other: ______

______Learning disability ______Other: ______

What are your personal strengths?: ______

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Goals for therapy: ______

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Anything else I should know: ______

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