Adult History Form - The Best Marriage

Basic Info

Tell us about yourself

Name(Required)

First Last

Today's Date(Required)

MM slash DD slash YYYY

Describe the circumstances that have contributed to your desire for counseling?(Required)

What do you hope to achieve by participating in counseling?(Required)

Symptoms

Mark the frequency of any of the symptoms listed blow that you have experienced

Anxiety(Required)

None

3 months

6 months

1 year

Year symptom began

Depressed mood(Required)

None

3 months

6 months

1 year

Year symptom began

Low energy level(Required)

None

3 months

6 months

1 year

Year symptom began

Racing thoughts(Required)

None

3 months

6 months

1 year

Year symptom began

Poor concentration(Required)

None

3 months

6 months

1 year

Year symptom began

Indecisiveness(Required)

None

3 months

6 months

1 year

Year symptom began

Change in sleeping(Required)

None

3 months

6 months

1 year

Year symptom began

Change in appetite(Required)

None

3 months

6 months

1 year

Year symptom began

Angry outbursts(Required)

None

3 months

6 months

1 year

Year symptom began

Crying spells(Required)

None

3 months

6 months

1 year

Number of times per week

Year symptom began

Lack of motivation(Required)

None

3 months

6 months

1 year

Year symptom began

Weight change(Required)

None

3 months

6 months

1 year

+ or - change

Year symptom began

Felling others are against them(Required)

None

3 months

6 months

1 year

Year symptom began

Excessive guilt(Required)

None

3 months

6 months

1 year

Year symptom began

Isolation(Required)

None

3 months

6 months

1 year

Year symptom began

Mood swings(Required)

None

3 months

6 months

1 year

Year symptom began

Feelings of hopelessness(Required)

None

3 months

6 months

1 year

Year symptom began

Low self-worth(Required)

None

3 months

6 months

1 year

Year symptom began

Difficulty remembering(Required)

None

3 months

6 months

1 year

Year symptom began

Thoughts, plans to self-harm(Required)

None

3 months

6 months

1 year

Year symptom began

Thoughts, plans to harm others(Required)

None

3 months

6 months

1 year

Year symptom began

Home Life

List the people who currently live in your home

Person #1

First Last

Person #1 Age

Relation to Person #1

Describe the current condition of your relationship with Person #1

Person #2

First Last

Person #2 Age

Relation to Person #2

Describe the current condition of your relationship with Person #2

Person #3

First Last

Person #3 Age

Relation to Person #3

Describe the current condition of your relationship with Person #3

Person #4

First Last

Person #4 Age

Relation to Person #4

Describe the current condition of your relationship with Person #4

What is your current living situation?

Family Info

Tell us about the relationships with your parents and siblings

What was the socioeconomic status of your family of origin?

Lower Class

Middle Class

Upper-Middle Class

Upper Class

In what way do you believe this status affected you?

Were your parents divorced?

Yes

What was your age at the divorce?

Did they remarry?

Yes

How old were you when they remarried?

Describe your relationship with your stepparent(s)

Is your father living?

Yes

What year did he pass?

Describe the best memory of your father

What has been disappointing about your relationship with your father?

What has been fulfilling about your relatioship with your father?

If you could change anything about your relationship with your father, what would that be?

Is your mother living?

Yes

What year did she pass?

Describe the best memory of your mother

What has been disappointing about your relationship with your mother?

What has been fulfilling about your relatioship with your mother?

If you could change anything about your relationship with your mother, what would that be?

Describe your most hurtful childhood memory

List your siblings, their names, age and your relationship. Click the "+" to add more.

Example 1: Sally, sister, 43, my relationship with Sally is great and we talk everyday. Example 2: Jack, brother, 45, I haven't spoken to Jack ion 10 years.

If a sibling was favored over others in your family, please describe and also note your current relationship with that sibling:

Developmental

Tell us about your childhood and teenage years

Describe any emotional or physical problems you had during your childhood and adolescence:

What were you like as a teenager (interests, dating, sports)?

Check the highest level of education you have obtained:

GED

High School

Vocational School

Technical School

Some College

Bachelor’s Degree

Master’s Degree

Doctoral Degree

List any learning difficulties you have

Marital

Tell us about current and past marriages

Current marital status

Not married

Married

Separated

Divorced

Widowed

Current Spouse

Age

Years Married

Things you enjoy about your marriage:

Things that are difficult about your marriage:

Describe the history of your relationship with your spouse:

Check all that apply to your marriage:

Physical abuse

Pornography

Infidelity

Lack of intimacy

Lack of trust

Financial problems

Lack of commitement

Drugs/alcohol

Poor communication

Conflict/arguing

Anger/resentment

Lack of respect

No longer in love

List any previous marriage(s) in chronological order (include ex-spouse name, age when married, age when divorced, reason for the divorce, and your current relationship).

(Example: Sally, married at 27, divorced at 45, divorced for infidelity, we currently do not speak)

Children from CURRENT marriage (include name, age, M/F and your current relationship with this child)

(Example: Jack, 4, M, I see Jack once a week per court order)

Children from PREVIOUS marriage(s) (include name, age, M/F and your current relationship with this child)

(Example: Jack, 4, M, I see Jack once a week per court order)

Medical

Tell us about you and your family's medical history

Describe any family history of psychiatric, emotional, drug or alcohol treatment or other health issues:

List any history of physical illness, injury or condition in your family:

Describe any history of psychiatric, emotional, drug or alcohol treatment or other problems in your present family:

Have you ever had an abortion?

Yes

If yes, include the number of abortions and the dates:

Your age at time of abortion:

Have you received post-abortion counseling?

Yes

If male, are you aware of an abortion conducted as a result of your pregnancy?

Yes

Include the number of abortions and your age at the time:

Is your spouse aware that this occurred?

Yes

Please explain:

Have you or your spouse ever had a miscarriage?

Yes

Include the number of miscarriages and the dates:

Have you ever had an eating disorder?

Yes

Please check all that apply:

Anorexia

Bulimia

Sexuality

Tell us a little about the sexuality in your marriage and more

Describe your earliest teaching about sex and sexuality:

Describe your current attitude about sex:

Are you currently or have you previously had gender identity concerns:

Yes

If yes, please explain:

List any history of homosexual involvement, including ages:

Have you ever been sexually abused?

Yes

If yes, what was your age(s) at the time of the abuse(s), and what were the ages of the abuser(s)?

Were adults aware of the abuse? Please explain:

Have you ever been sexually abusive to others?

Yes

If yes, your age at the time of the abuse(s) and the age(s) of your victim(s):

Have you ever been raped?

Yes

What was your age?

Have you received counseling?

Yes

If yes, what was the outcome:

Do you view internet/other pornography?

Yes

How often?

Is your spouse aware of your involvement in this activity?

Yes

Briefly explain how concerned you are about your pornography involvement:

Religion

Tell us about your relationship with God

Describe the role God had in the home in which you grew up:

In what church were you primarily involved?

Currently, what church, if any, are you involved in and to what extent?

Describe your view of God:

How does God currently play a part in your life?

What do you consider God’s role to be in counseling?

Legal

Tell us if you have a history of arrests or felonies

Have you ever been arrested?

Yes

If yes, please explain:

Date of arrest:

Outcome/Status of arrest:

Have you ever been convicted of a felony?

Yes

If yes, please explain:

Are you on probation?

Yes

If yes, when does it end?

Name and phone number of your probation officer:

Addictions

Tell us your history with alcohol, drugs and gambling

Do you drink alcoholic beverages?

Yes

How often?

Are you concerned about your drinking?

Yes

Are others close to you concerned about your drinking?

Yes

Please explain why others are concerned about your drinking:

Do you use illegal drugs?

Yes

If yes, how often?

Are you concerned about your drug use?

Yes

Are others concerned about your drug use?

Yes

Please explain why others are concerned about your drug use:

Do you engage in gambling?

Yes

If yes, how often and what type?

Are you concerned about your gambling?

Yes

Are others concerned about your gambling?

Yes

Please explain why others are concerned about your gambling:

Name

This field is for validation purposes and should be left unchanged.