PART 1: BACKGROUND AND CURRENT CONCERNS
Name *
Name
Date of Birth
Date of Birth
Address
Address
Emergency Contact Details
Emergency Contact Name
Emergency Contact Name
Address
Address
This form is intended to help me understand you, your present concerns, and your needs in our work together. If you have any questions or if you are not clear about any of these items, please put a question mark (?) and we can talk about it together in our next session.
Check any of the following that accurately describe your present or recent experience. Check all that apply to you.
I have been having experiences of...
What are your sources of strength?
Please tick any of the following that you consider to be sources of strength for you. Feel free to add your own in the blank space beneath.
For example when someone is feeling depressed it can become difficult for them to be kind to themselves or others.
How do you cope?
How can I help you?
Part 2: EMOTIONAL LIFE
Which of the following expressions of emotions were discouraged when you were a child? Please check all that apply.
Please read each statement and select a number 0, 1, 2, or 3 which indicates how much the statement applied to you OVER THE PAST WEEK. There are no right or wrong answers. Do not spend too much time on any one statement.
PART 3: FAMILY HISTORY
Each of the following statements describes experiences you may have had as a child. Check all that apply to you and your childhood. Please add comments or questions in the space below. If you are not sure about an item, of it it feels too private, place a question mark next to it.
My mother...
My father...
When I was a child I was sexually intimate with...
Part 4: Spirituality
Part 5: Recreation