The Best Marriage

Adult History Form (Signed)


Basic Info

Name:

Date:

Email:

Describe The Circumstances That Have Contributed To Your Desire For Counseling?

 

What Do You Hope To Achieve By Participating In Counseling?

 

Symptoms

Anxiety: 

Year Began:

Depressed mood:

Year Began:

Low energy level:

Year Began:

Racing thoughts:

Year Began:

Poor concentration:

Year Began:

Indecisiveness:

Year Began:

Change in sleeping:

Year Began:

Change in appetite:

Year Began:

Angry outbursts:

Year Began:

Crying spells:

Number of times per week:

Year Began:

Lack of motivation:

Year Began:

Weight change:

+/- Change:

Year Began:

Feeling others are against them:

Year Began:

Excessive guilt:

Year Began:

Isolation:

Year Began:

Mood swings:

Year Began:

Feelings of hopelessness:

Year Began:

Low self-worth:

Year Began:

Difficulty remembering:

Year Began:

Thoughts, plans to harm self:

Year Began:

Thoughts, plans to harm others:

Year Began:

Home Life

Person #1:

Person #1 Age:

Relation to Person #1:

 
 
 

Person #2:

Person #2 Age:

Relation to Person #2:

 
 

Person #3:

Person #3 Age:

Relation to Person #3:

 
 

Person #4:

Person #4 Age:

Relation to Person #4:

 
 
 
 
 
 
 

Family Info

What was the socioeconomic status of your family of origin?

 

 
 
 
Were your parents divorced?
 
 
Did they remarry?
 
 
 
 
 
Is your father living?
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
Is your mother living?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
List your siblings, their names, age and your relationship. Click the "+" to add more:
 
 
 
 
 
 
 
 
 

Developmental

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

 

 

 
 
 
 
Check the highest level of education you have obtained: 
 
 
 
 

Marital

Current marital status:

 
Current Spouse Age:
 
 
 
 
 
 
 
 
 
 
 
Check all that apply to your marriage:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Medical

 
 
 
 
 
 
 
 
 
Have you ever had an abortion? 
 
 
 
 
Have you received post-abortion counseling?
 
If male, are you aware of an abortion conducted as a result of your pregnancy? 
 
 
 
Is your spouse aware that this occurred?
 
 
 
 
Have you or your spouse ever had a miscarriage?
 
 
 
 
Have you ever had an eating disorder?
 
Please check all that apply:
 

Sexuality

 
 
 
 
 
 
Are you currently or have you previously had gender identity concerns:
 
 
 
 
 
 
 
Have you ever been sexually abused?
 
 
 
 
 
 
 
Have you ever been sexually abusive to others?
 
 
 
 
Have you ever been raped?
 
 
Have you received counseling?
 
 
Do you view internet/other pornography?
 
 
Is your spouse aware of your involvement in this activity?
 
 
 

Religion

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Legal

Have you ever been arrested?

 
 
 
 
 
 
 
Have you ever been convicted of a felony?
 
 
 
 
Are you on probation?
 
 
 

Addictions

Do you drink alcoholic beverages?

 
Are you concerned about your drinking?
 
Are others close to you concerned about your drinking?
 
 
 
 
Do you use illegal drugs?
 
 
Are you concerned about your drug use?
 
Are others concerned about your drug use?
 
 
 
 
Do you engage in gambling?
 
 
Are you concerned about your gambling? 
 
Are others concerned about your gambling? 
 
 
 
 
 

Leave this empty:

Signature arrow sign here

Signed by Charles Coulter
Signed On: July 10, 2024


Signature Certificate
Document name: Adult History Form (Signed)
lock iconUnique Document ID: 24e0ab20409b29dd2528ed627fa1bf00342f65eb
Timestamp Audit
July 5, 2024 8:53 am CDTAdult History Form (Signed) Uploaded by Charles Coulter - coultercounseling@gmail.com IP 35.149.231.155