HISTORY QUESTIONNAIRE

YOUR NAME:                                                                      Age:                  Today’s Date:                                      

Referred by - Name:                                    Agency:                                       May I send thank-you? oYes   oNo

Primary Physician’s Name:                                                                     Phone#:                         Last Exam:                

   Practice Name:                                                                                   Location:                                                       

   Relevant medical history/allergies:                                                                                                                              

   Current medications (including birth control):                                                                                                              

   Past long-term medications:                                                                                                                                       

   Would you like your physician to know that you are coming to therapy, and your progress here?  oYes   oNo

Previous therapist:                                                                                   Approx. # sessions:         When:                     

   Previous therapy issues:                                                                                                                                            

Previous therapist:                                                                                   Approx. # sessions:         When:                     

   Previous therapy issues:                                                                                                                                            

Hospitalizations:  oMental health    oChemical Dependency                  When:                                                            

Religious affiliation:                                         Religion’s importance to you: o Not at all          o Somewhat     o Very

Have you had thoughts of suicide in the last month? o Yes  o No           Have you had plans/attempts? o Yes  o No

RELATIONSHIP STATUS:       oSingle     oMarried/Partnered     oSeparated     oDivorced     oWidowed

   # of Marriages/Long term Partnerships & length/dates:                                                              

OTHER ADULT(S) WHO LIVE WITH YOU:

   Name:                                                      o M  o F    Age:             Relationship:                            Length:                       

   Name:                                                      o M  o F    Age:             Relationship:                            Length:                    

YOUR SIGNIFICANT OTHER (if not living with you):

   Name:                                                      o M  o F    Age:             Relationship:                            Length:               

PLEASE LIST ALL CHILDREN:

   Name:                                                      o M  o F    Age:             Rel’nshp:                        Live w/you?    oY oN

   Name:                                                      o M  o F    Age:             Rel’nshp:                        Live w/you?    oY oN

   Name:                                                      o M  o F    Age:             Rel’nshp:                        Live w/you?    oY oN

   Name:                                                      o M  o F    Age:             Rel’nshp:                        Live w/you?    oY oN

The primary problem that has brought you to therapy:                                                                                                   

The goals you hope to achieve in therapy: