INFORMATION AND HISTORY FORM

Name									  Date				

Date of Birth							

Name used in childhood					   Place of Birth				

Please list health problems during infancy and childhood:

															

Please list health problems during adolescence:

															

With whom did you live:

as a child								

as an adolescent							

FAMILY HISTORY

			 Age	          Marital              Place of 	               Drug or	         Psychological
Name	                   (or Deceased)            Status             Residence            Alcohol Problems          Problems     

PARENTS:

___________                                                                                                                                                      

___________                                                                                                                                                      

SISTERS & BROTHERS:

___________                                                                                                                                                      

___________                                                                                                                                                      

___________                                                                                                                                                      

___________                                                                                                                                                      

___________                                                                                                                                                      

CHILDREN & STEPCHILDREN:

___________                                                                                                                                                      

___________                                                                                                                                                      

___________                                                                                                                                                      

___________                                                                                                                                                      

PARTNER/SPOUSE:

___________                                                                                                                                                      

Did any extended family members have psychological or drug or alcohol problems?

															

Any family medical problems?										

EDUCATION (where and highest grade level completed):					

EMPLOYMENT HISTORY

Current job:							  Duration:					

Prior job:								  Duration:					

Prior job:								  Duration:					

RELATIONSHIP  HISTORY

Date(s) of significant relationship(s) & marriage(s):							

With whom do you live currently:										

Have you every been physically, sexually, or verbally abused?					

HISTORY OF LEGAL PROBLEMS

SPIRITUALITY

AREAS OF INTEREST/HOBBIES

DRUG OR ALCOHOL USE (frequency & amount)

Tobacco						   Recreational Drug Use				

Caffeine						   If you have history of heavier alcohol or drug

Alcohol						   use, when was this & how much did you 

							   consume							

Please describe the area(s) of concern for which therapy is being sought at this time:

															

Please list any prior therapy:											

Please list current medications:										

General medical problems:											

Additional information you would like me to know: