PERSONALITY INFORMATION

Have you ever had any psychotherapy or counseling before?: Yes: ___ No: ___
If yes, List Counselor or Therapist: ____________________________________
Circle any of the folloing ords hich see! to describe you no:
"ctive "!bitious #elf$confident %ersistent Hard$or&ing Nervous I!patient I!pulsive
'oody (ften$blue )*citable I!aginative Cal! #erious )asy$going +ood$natured #hy
Introvert )*trovert Li&able Leader Hard$boiled #ub!issive ,uite #elf$conscious Lonely
MARRIAGE INFORMATION: If Never 'arried, chec& here -___. and o!it this section/
Na!e of #pouse: _______________________ "ddress: ___________________________________
%hone: ___________________ (ccupation: ____________________________________________
Is #pouse 0illing to co! for counseling?: Yes: ___ No: ___ 1ncertain: ___
Have either of you ever filed for divorce?: Yes: ___ No: ___ If Yes, hen?: ________
2ate of This 'arriage: _________________ Your ages hen !arried: Husband: ___ 0ife: ___
Ho long 2id You 3no Your #pouse 4efore 'arriage?: _______________
Length of #teady 2ating 0ith #pouse: ______________ Length of )ngage!ent: _______________
+ive 4rief Infor!ation about any previous !arriage: ______________________________________
_________________________________________________ 4ro&en by: 2ivorce: ___ 2eath: ___
List your children in birth order:
%'5 Na!e "ge #e* Living )ducation 'arital #tatus
5Chec& This Colu!n if Child is by %revious 'arriage
PARENTAL FAMILY HISTORY:
0ere you reared by your blood parent?: Yes: ___ No: ___
0ere your parents divorced?: Yes: ___ No: ___
0as your childhood ho!e bro&en by the death of one or both of your parents?: Yes: ___ No: ___
0ere you reared by foster parents, adoptive parents or step parents?: Yes: ___ No: ___
If Yes, )*plain: ___________________________________________________________________
"nser this section describing your parents or parent substitute:
6ather 'other
#till Living: -yes7no. _____ _____
"ges at 'arriage _____ _____
Nationality 4ac&ground _______________ _______________
)ducation -8 of Years. _____ _____
5If parent-s. is7are still living, co!plete the folloing in a si!ilar !anner:
5"ges no _____ _____
5Church "ttendance per !onth _____ _____
59ate your parent:s !arriage: 1nhappy: ___ "verage: ___ ;ery Happy: ___
"s a child, did you feel closet to your: 6ather: ___ 'other: ___ "nother: ___
9ate Your Childhood Life: ;ery Happy: ___ Happy: ___ "verage: ___ 1nhappy: ___
List your brothers and sisters in birth order
Na!e "ge #e* Living 'arital #tatus If !arried, rate the !arriage
Happy "verage 1nhappy 2ivorce
Happy "verage 1nhappy 2ivorce
Happy "verage 1nhappy 2ivorce
Happy "verage 1nhappy 2ivorce
Happy "verage 1nhappy 2ivorce