Adult Background Form

Date___________

Name______________________________________ Sex___ Age___ Birthdate__________

Address_____________________________________ City____________ State___ Zip_____

Phone: Work_______________ Cell_________________ Home___________________

The information you give below is for professional use only and will be held as confidential.

In your own words, what difficulties or problems bring you here at this time?

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When are these problems worse? __________________________________________________________

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When are they better? ____________________________________________________________________

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Have you tried previously to get any help for this? Yes___ No___
If yes, what kind?

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When? ___________________________ Where? ______________________________________________

Was this helpful? ___________How? ________________________________________________________

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When did these problems first begin? _________________________________________________________

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What have you tried on your own? _________________________________________________

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Have you ever thought of hurting yourself?__________ Have you ever actively tried to hurt yourself?____________

How long have you been drinking alcohol? _____________________________________________________

How frequently do you drink alcohol? ________________________________________________________

How much alcohol do you drink each day? _______________________________________________________

Do you consider yourself or any member of your family to have an alcohol or drug problem? Yes__ No__

Explain___________________________________________________________________________________

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Has any member of your family been treated for problems with alcohol?

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Please list any drugs or medications you have used or are using:

Your Age at
Date Time of Use Drug Frequency Reason for Taking Drug

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Are you aware of any physical problems accompanying your birth? ___________________________________

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Describe any physical problems during childhood:_________________________________________________

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How old were you when you began dating? _________

How often did you date as a teenager? ____________

Describe any problems you have now with persons of the opposite sex as a teenager: ___________________

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(If you are not married and have never been married, please skip over to the section on Family History.)

What is your marital status now? Married_____ Divorced_______ Widowed_______

How long have you been married to your present husband/wife?__________________

How old is he/she? ________ What is his/her education?_________________________________________

What is her/her occupation? _________________________________________________________________

How many times have you been married? _______________________ How long each time?______________

Please explain how and why you separated. _____________________________________________________

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What kind of person is your husband/wife?_______________________________________________________

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How long did you know him/her before you were married? __________________________________________

What do you enjoy most about your marriage? ___________________________________________________

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What do you enjoy least about your marriage? ____________________________________________________

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Does your husband/wife have a present illness or physical defect?____________________________________

Please describe:____________________________________________________________________________

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Do you feel a need to straighten out your marriage? _______________________________________________

Why and in what way? ______________________________________________________________________

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Who handles the money? ___________________________________________________________________

Is there every any trouble about this arrangement? (Explain) ________________________________________

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If your spouse were to describe you, what would he/she say? ________________________________________

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Occupation

Are you presently employed? ___________________

What is yourr occupation? _________________________________________________________________

If you would do any type of work you wanted, what would you chose? _________________________________