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TODAY'S DATE:
Name:
Date of Birth:
Complete Address:
Home Phone:
Mobile Phone:
Business Phone:
Email Address:
Nationality:
Religion:
Profession:
Number of years
married/committed to current spouse/partner:
Previous
Marriage(s)/commitment(s) and length of marriage(s)/commitment(s):
Child(ren)'s names
and ages:
YOUR FAMILY OF ORIGIN
Mother:
Name:
Age:
Occupation:
Nationality:
Religion:
Write 3 positive
adjectives to describe your mother:
1.
2.
3.
Write 3
negative adjectives to describe your mother:
1.
2.
3.
Father:
Name:
Age:
Occupation:
Nationality:
Religion:
Write 3 positive
adjectives to describe your father:
1.
2.
3.
Write 3 negative
adjectives to describe your father:
1.
2.
3.
BROTHERS AND SISTERS
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Name
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Age
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Education
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Occupation
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Married?
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# of
Children
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Therapy History
Please provide a list of therapists you have seen starting with most current.
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Name
of Therapist
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Dates
Seen
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Individual
or Couples
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HEALTH CHECKLIST
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You
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Spouse/Partner
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Child
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Anger
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Anxiety
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Depression
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Drinking
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Substance
Abuse
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Workaholism
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Food
Addiction
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Spending/Gambling
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Sex
Addiction
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Please note if you, your spouse/partner have any significant health issues.
Please provide a description of current
issues/problems you would like addressed in couple's therapy:
When your partner is really stressed
out, give a description of them at their worst:
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