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Answer
as completely as you can. Thank you very much.
Date of Evaluation: _____________________________
Referred by: ___________________________________
References:
Name
Relationship
Contact No.
YOUR SPOUSE
Name:
Age:
Address:
Date of Marriage:
Place of Marriage:
Date of Separation:
Names and Birthdates of your children:
Describe your relationship with your parents and how they treated you:
Did you experience any crisis in your family? (Ex: vices, mental/ psychological
illness, legal problems, etc.):
Your citizenship:
Your religion:
Your Educational attainment:
Your occupation:
Before marriage:
During marriage:
After separation:
Background information about your SPOUSE:
Date of Birth:
Place of Birth:
How many brothers:
How many sisters:
About his/her parents:
Father:
Education and Occupation:
Mother:
Education and Occupation:
Describe his/her relationship with his/her parents, how he/she treats them and
how they treat him/her:
Are any of his / her family members with vices? What kind of vices?
His/her citizenship:
His/her religion:
His/her educational attainment:
His/her occupation:
Before marriage:
During Marriage:
After Separation:
How did you spend your honeymoon? Did you have any frustrations?
Where did you stay after the wedding? List all places where you lived.
Complete account of your marital experiences: (Please include your and your
spouses behaviors and attitudes, how you treated each other, your activities
together and why your marriage failed. Cite incidents)
How did you separate? Did you have efforts for reconciliation? In whose custody
are the children?
Complete the following sentences. Write the first thing that comes to your mind:
Someday, I want to __________________________________________________.
That worst thing I ever did ____________________________________________.
I believe I have ability to _____________________________________________.
My greatest weakness is _____________________________________________.
I am afraid of ______________________________________________________.
If there is a problem_________________________________________________.
When I was a child, _________________________________________________.
___________alone
2. I believe in my intuition
_____________often
___________rarely
____________feelings