Your first therapy session

If you are planning to see me for therapy, it is helpful for me to know more about your background. You can print this form, fill in the blanks, and bring it to your first (or next) therapy session. If you prefer not to complete this form or to complete only parts of it you wish to, that is fine. You are in charge of what you share and when, and of what you choose not to share, during your therapy experience.

Date: _________________
PSYCHOSOCIAL HISTORY FORM
Name: ___________________________________ Age: _______ DOB: ___/___/___
Race: _______________________ Sex: ___________
Address: ____________________________________________________
____________________________________________________________
____________________________________________________________
Home Phone: ________________ cell phone __________
Occupation: ___________________________
Work Phone: ___________________________
Marital Status: _________________________

Children:
Name Age Date of Birth
1. ______________________ ______ ___________
2. ______________________ ______ ___________
3. ______________________ ______ ___________
4. ______________________ ______ ___________

PARENT AND FAMILY HISTORY
What city did you live in while growing-up? __________________________________
Who raised you? ________________________________________________________
How was the relationship between your parents? ______________________________________________________________________
______________________________________________________________________
If your parents were married, was there any history of separations or divorce? Yes No
If yes, explain: ____________________________________________________
_________________________________________________________________
Father
Name: _______________________________
Current age: __________
If deceased, at what age did he die? ____________ Cause: _________________
Describe your father: _______________________________________________
_________________________________________________________________
_________________________________________________________________
Highest educational level attained: _________________
Occupation: ___________________________________
Number of hours worked per week during your childhood: ______________
History of excessive alcohol or drug abuse? Yes No If yes, explain:
_________________________________________________________________
_________________________________________________________________
History of legal problems? Yes No If yes, explain: ___________________
_________________________________________________________________
History of emotional problems (mental illness)? Yes No If yes, explain: ___
____________________________________________________________________
_____________________________________________________________________
Primary method of discipline: ____________________________________________

Mother
Name: _______________________________
Current age: __________
If deceased, at what age did she die? ____________ Cause: ________________
Describe your mother: ________________________________________________
____________________________________________________________________

_________________________________________________________________
Highest educational level attained: _________________
Occupation: ___________________________________
Number of hours worked per week during your childhood: ______________
History of excessive alcohol or drug abuse? Yes No If yes, explain: ______
_________________________________________________________________
History of legal problems? Yes No If yes, explain: _________________
_________________________________________________________________
History of emotional problems (mental illness)? Yes No If yes, explain: ___
__________________________________________________________________
Primary method of discipline: _________________________________________
Where do your parents currently reside: _______________________________________
_______________________________________________________________________
Did either parent abuse or neglect you? Yes No If yes, explain: _________________________________________________________
_______________________________________________________________________
If you could change anything about your parents or family, what would it be?

_______________________________________________________________________
_______________________________________________________________________
Stepparent
Name: _______________________________ Sex: ____________
Current age: __________ Year married to parent: _____________
If deceased, at what age did he die? ____________ Cause: _________________
Describe stepparent: ________________________________________________
_________________________________________________________________
_________________________________________________________________
Highest educational level attained: _________________
Occupation: ___________________________________
Number of hours worked per week during your childhood: ______________
History of excessive alcohol or drug abuse? Yes No If yes, explain: ______
_________________________________________________________________
History of legal problems? Yes No If yes, explain: _________________
_________________________________________________________________
History of emotional problems (mental illness)? Yes No If yes, explain: ___
__________________________________________________________________
Primary method of discipline: _________________________________________

Siblings
#1 Name:_______________________________ Sex: Male Female
Age: _______________
Occupation: ______________________ Educational Level: _____________
Married: Yes No Number of divorces: ____________
Number of children: ____________
Resides in what city/town? ____________________________
History of mental illness? Yes No If yes, explain: ____________________
_________________________________________________________________
History of alcohol or drug abuse? Yes No If yes, explain: ________________
__________________________________________________________________
History of criminal behavior? Yes No If yes, explain: _________________
__________________________________________________________________
How often do you see this sibling: ______________________________________
How does this sibling get along with your children: ________________________
__________________________________________________________________
How close are you to this sibling: 1 2 3 4 5
not at all extremely

#2 Name:_______________________________ Sex: Male Female
Age: _______________
Occupation: ________________________ Educational Level: _____________
Married: Yes No Number of divorces: ____________
Number of children: ____________
Resides in what city/town? ____________________________ Psychosocial History

History of mental illness? Yes No If yes, explain: ____________________
_________________________________________________________________
History of alcohol or drug abuse? Yes No If yes, explain: ________________
__________________________________________________________________
History of criminal behavior? Yes No If yes, explain: _________________
__________________________________________________________________
How often do you see this sibling: ______________________________________
How does this sibling get along with your children: ________________________
__________________________________________________________________
How close are you to this sibling: 1 2 3 4 5
not at all extremely

#3 Name:_______________________________ Sex: Male Female
Age: _______________
Occupation: ________________________ Educational Level: ____________
Married: Yes No Number of divorces: ____________
Number of children: ____________
Resides in what city/town? ____________________________
History of mental illness? Yes No If yes, explain: ____________________
_________________________________________________________________
History of alcohol or drug abuse? Yes No If yes, explain: ________________
__________________________________________________________________
History of criminal behavior? Yes No If yes, explain: _________________
__________________________________________________________________
How often do you see this sibling: ______________________________________
How does this sibling get along with your children: ________________________
__________________________________________________________________
How close are you to this sibling: 1 2 3 4 5
not at all extremely

#4 Name:_______________________________ Sex: Male Female
Age: _______________
Occupation: ______________________ Educational Level: _____________
Married: Yes No Number of divorces: ____________
Number of children: ____________
Resides in what city/town? ____________________________
History of mental illness? Yes No If yes, explain: ____________________
_________________________________________________________________
History of alcohol or drug abuse? Yes No If yes, explain: ________________
__________________________________________________________________
History of criminal behavior? Yes No If yes, explain: _________________
__________________________________________________________________
How often do you see this sibling: ______________________________________
How does this sibling get along with your children: ________________________
__________________________________________________________________
How close are you to this sibling: 1 2 3 4 5
not at all extremely

#5 Name:_______________________________ Sex: Male Female
Age: _______________
Occupation: _______________________ Educational Level: _____________
Married: Yes No Number of divorces: ____________
Number of children: ____________
Resides in what city/town? ____________________________
History of mental illness? Yes No If yes, explain: ____________________
_________________________________________________________________
History of alcohol or drug abuse? Yes No If yes, explain: ________________
__________________________________________________________________
History of criminal behavior? Yes No If yes, explain: _________________
__________________________________________________________________
How often do you see this sibling: ______________________________________
How does this sibling get along with your children: ________________________
__________________________________________________________________
How close are you to this sibling: 1 2 3 4 5
not at all extremely

#6 Name:_______________________________ Sex: Male Female
Age: _______________
Occupation: _______________________ Educational Level: ____________
Married: Yes No Number of divorces: ____________
Number of children: ____________
Resides in what city/town? ____________________________
History of mental illness? Yes No If yes, explain: ____________________
_________________________________________________________________
History of alcohol or drug abuse? Yes No If yes, explain: ________________
__________________________________________________________________
History of criminal behavior? Yes No If yes, explain: _________________
__________________________________________________________________
How often do you see this sibling: ______________________________________
How does this sibling get along with your children: ________________________
__________________________________________________________________
How close are you to this sibling: 1 2 3 4 5
not at all extremely

Significant Events in Your Life (i.e., losses, moves, injuries, honors, championships, etc)
Ages birth to 5 : _______________________________________________
_______________________________________________
_______________________________________________
Ages 6-10: _______________________________________________
_______________________________________________
_______________________________________________
Ages 11-15 _______________________________________________
_______________________________________________
_______________________________________________
Ages 16-20 ________________________________________________
________________________________________________
________________________________________________
Ages 21-30 ________________________________________________
________________________________________________
________________________________________________
Ages 31 to present ________________________________________________
________________________________________________
________________________________________________

Number of suspensions from school: _____________
Did you graduate from high school? Yes No If yes, when? _______________
Grade point average in high school ___________
Sports or clubs you participated in school: _______________________________
__________________________________________________________________
Did you receive any tutoring, counseling, or special education assistance during
your schooling? Yes No If yes, explain: _____________________
____________________________________________________________
Please list any post-high school training:
School: _______________________________ Date _____ to _______
Type of Training or Major______________________________________
Degree: ____________________ Grade Point Average: __________
School: ________________________________ Date _____ to _______
Type of Training or Major______________________________________
Degree: ____________________ Grade Point Average: __________
Armed Services Experience
Were you in the armed services? Yes No If no, please go to next section.
Branch ______________________________ Length of time served __________
Type of work ____________________________________________________________
Highest rank achieved ______________________________
Any awards/commendations received? Yes No Describe: ___________________
Any disciplinary action? Yes No If so, why: ______________________________
Type of discharge: _________________________________
Feelings/thoughts about time in service ________________________________________
__________________________________________________________________
Employment History
Current employer: ________________________________________________________
Type of work: ________________________________________________________

Dates of Employment From:__________ To:_____________
Work hours:
Monday _______ to __________
Tuesday _______ to __________
Wednesday _______ to __________
Thursday _______ to __________
Friday _______ to __________
Saturday _______ to __________
Sunday _______ to __________
How often do you work weekends? ___________________________________________
On average, how many hours do you work per week? ______________
Current salary $_________________
Do you have medical insurance from your employer? Yes No
How would you describe your work record on this job? Poor Fair Good Very Good
Is this job stable? Yes No If no, explain: _______________________________
________________________________________________________________________
Do you have any other employment? If so, explain: ______________________________
________________________________________________________________________
Past Employment:
Name of company: _______________________________________________________
Type of work: ___________________________________________________________
Dates of Employment: From ____________ To: _____________
Reason for leaving: _______________________________________________________
Name of company: _______________________________________________________
Type of work: ___________________________________________________________
Dates of Employment: From ____________ To: _______________
Reason for leaving: _______________________________________________________
Name of company: _______________________________________________________
Type of work: ___________________________________________________________
Dates of Employment: From: ____________ To: ______________
Reason for leaving: _______________________________________________________
Financial Situation
How is your financial situation at this time? (circle one)
Terrible Fair Good Very Good
How much are you in debt, other than mortgage or car payments? $______________
Have you ever filed for bankruptcy? Yes No If yes, explain: ______________
______________________________________________________________
At this time, are you able to pay bills and provide essential needs for your children?
Yes No If no, explain: ______________________________________
________________________________________________________________
Do you gamble? Yes No If so, describe: _________________________________
________________________________________________________________
Physical Health
How would you describe your current physical health? (circle one)
Poor Fair Good Very Good Excellent
Height: ___________ Weight: _____________
Eye color: _______________ Hair color: ___________________________
Name of Physician: __________________________________
Last physical exam: __________________________________
List any medical problems: ___________________________________________
___________________________________________
___________________________________________
___________________________________________
List any past surgeries: ___________________________________________
___________________________________________
___________________________________________
Do you have any scars or tattoos? Yes No Is so, explain: _________________
__________________________________________
Current medications: ___________________________________________
___________________________________________
___________________________________________
Mental Health
How would you describe your mental and emotional health at this time? (circle one)
Poor Fair Good Very Good Excellent
Have you ever received therapy or counseling for emotional or mental problems?
Yes No If yes, please identify the reasons, dates, and clinic/therapist,
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Have you ever taken medication for emotional problems? Yes No If yes, please
describe: _________________________________________________________
_________________________________________________________________
_________________________________________________________________
Are you currently taking medication for emotional problems? Yes No If yes,
please describe: ____________________________________________________
_________________________________________________________________
Have you ever been hospitalized because of emotional problems? Yes No
If yes, please identify the hospital, dates, and reason: ______________________
_________________________________________________________________
Current stressors in your life: _______________________________________________
_________________________________________________________________
Do you have any history of self-inflicted injuries or cuts? Yes No If so, explain:
__________________________________________________________________
__________________________________________________________________
Do you have any history of suicide attempts? Yes No If yes, how many times,
why, & when? _____________________________________________________
_________________________________________________________________
Any history of sexual abuse? Yes No If yes, describe: ____________________
_________________________________________________________________
_________________________________________________________________
Substance Abuse
What type of alcohol beverages do you enjoy? __________________________________
How often do you consume alcoholic beverages? ________________________________
How much alcohol do you usually consume when drinking? _______________________
How many times have you been intoxicated (drunk) during the past year? ____________
During the past five years? _____________________
Have you ever experienced black outs from consuming alcohol? Yes No If so,
explain: ___________________________________________________________
Has anyone ever expressed concern about your alcohol consumption? Yes No
If so, who and why? _________________________________________________
Have you ever received a DUI (driving under the influence) conviction? Yes No
If so, explain: ______________________________________________________
__________________________________________________________________
What types of drugs have you used: (check those that apply)
____ Marijuana ____ Cocaine ____ LSD
____ Heroin ____ Speed ____ Barbiturates
If any of the above is checked, please describe the age you started using the drug
and amount of usage: _______________________________________________
_________________________________________________________________
_________________________________________________________________
Did you ever sell drugs? Yes No
Have you ever attended AA or received therapy for substance abuse? Yes No
If so, explain: _____________________________________________________
_________________________________________________________________
Do you smoke tobacco? Yes No If so, how many packs of cigarettes do you
consume per day? ________

Legal or Criminal History
Have you ever been detained or arrested? Yes No If so, explain: ___________
__________________________________________________________________
__________________________________________________________________
Have you ever been charged with a crime? Yes No If so, explain: ____________
__________________________________________________________________
Have you ever been convicted of a crime? Yes No If so, explain: ______________
__________________________________________________________________
Were you ever in jail or prison? Yes No If so, explain: ______________________
__________________________________________________________________
Has your driver’s license ever been suspended? Yes No If so, describe: _________
__________________________________________________________________
Religious Beliefs
Were you raised according to a certain religious faith? Yes No If so, explain: _____
__________________________________________________________________
What is your current religious affiliation? ______________________________________
Do you attend services on a regular basis? Yes No
Are religious issues an area of controversy in the raising of the children? Yes No
If yes, please describe: _______________________________________________
__________________________________________________________________
__________________________________________________________________
Interests
Please describe your interests:
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________

Social Network
Please describe people that you can rely on for assistance or help:
_____________________________ ______________________________
_____________________________ ______________________________
Current Residence
Describe your current residence:
Circle one: apartment condo home
Square footage: ___________
Number of bedrooms: ___________

What are the advantages of this residence? ____________________________________
_________________________________________________________________
What are the disadvantages of this residence? __________________________________
_________________________________________________________________
Do you plan to remain in this residence? Yes No If no, explain: _____________
_________________________________________________________________
_________________________________________________________________
Relationship History
At what age did you start dating? _________
How many different boyfriends/girlfriends did you have in high school? _________
How many long-term relationships (6 months or longer) have you had? __________
How many times have you been married? _________
Dates of marriage(s): __________________________________________________
If previously divorced (other than this dispute), what was the reason(s):___________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Do you have children from any other relationship? Yes No If so, please provide
name(s) and age of child(ren): 1)______________________________
2) ________________________ 3) ___________________________
In terms of the current dispute, what originally attracted you to this person?
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
What made you decide to marry this person?
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Please check any of the following that were problems during the relationship:
____ arguing ____ money misuse _____ job problems
____ drug abuse ____ alcohol abuse _____ sexual problems
____ sexual affairs ____ child rearing issues _____ domestic violence
____ ill health ____ emotional distance _____ lack of love
What made you decide to terminate the relationship with this person? ___________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
What is the relationship like between this person and the children? ______________
______________________________________________________________
______________________________________________________________
______________________________________________________________

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