Getting Started in Counseling

• As You Begin Counseling

• Intake Form

• Confidentiality Rules

• Home

BIOGRAPHICAL DATA

 Please "copy" this form and "paste" it to a word processor and complete it.  Print it and bring it to your first session. Or you may print the form (from your browser window) and fill it out by hand.  Please sign it at the bottom.

Date: ________ Return to: GAMBLERS COUNSELING CENTER

Name: ________________________ Sex: ___ Age: ___ Birth Date ________

Address: ___________________________________________ Phone: ______

                  Street                                                               City                State      Zip

        The information you give in answering the questions below will assist in helping you change.  Please answer carefully.  Use the reverse side of the page if you need additional space for your answers.

1. What is your primary problem? ____________________________________

________________________________________________________________

2. What is your secondary problem? __________________________________

3. What kind(s) of help have you tried to get previously? ________________

________________________________________________________________

4. Who referred you? ______________________________________________

5. What were the circumstances of this referral? ________________________

________________________________________________________________

CHILDHOOD HISTORY

6. Birthplace: _____________________________________________________

7. What is your earliest memory? _____________________________________
_________________________________________________________________

8. How would you describe yourself as a child? _________________________

_________________________________________________________________

9. As a child, what kinds of bad feelings did you have? ___________________
_________________________________________________________________

10. Which parent named you? _________ Why did they pick those names? _________________________________________________________________

11. What did your mother hope you’d be as an adult? ____________________

12. What did your father hope you’d be as an adult? _____________________

13. Was it easy or hard for you to make friends as a child? _____ Explain: ___
_________________________________________________________________

14. What people did you feel close to as a child? _________________________

15. Did your family move often? _________ Please describe your reactions to the moves: ___________________________________________________________

16. Who chose your friends, you or your parents? ________________________

17. Did you play with both boys and girls? ______________________________

18. What were your favorite types of play? _____________________________

19. What were your favorite pastimes? ________________________________

20. What did/does your mother usually say when you did/do something wrong or  disappoint her? _________________________________________________

21. What did/does your father usually say when you did/do something wrong or    disappoint him? __________________________________________________

22. What nicknames have people called you? ___________________________

23. What do the names mean? _______________________________________

24. What was your mother’s favorite saying? ____________________________

25. What was your father’s favorite saying? _____________________________

26. How did you think you would turn out? ______________________________

SCHOOL HISTORY
 

27. What grade schools did you attend and when did you finish? ___________

_________________________________________________________________

28. What high schools did you attend and when did you finish? ____________

_________________________________________________________________

29. What is the highest grade you completed? __________________________

30. What degrees or diplomas do you have? _____________________________

31. What kind of student were you? ___________________________________

32. What were your favorite subjects? _________________________________

33. How old were you when you left school? ____________________________

34. Did you go as far in school as you wanted to go? _____________________

35. If you had it to do over again, how far would you go? _________________

DATING AND PRIMARY RELATIONSHIPS

36. How old were you when you began dating? __________________________

37. How long in this relationship? _____  How old is he/she? ______________

38. How many times have you been in a primary relationship? _____________

39. Why did you leave the relationships before the current one? ___________

40. Does your significant other have physical or emotional problems? _______

           If yes, what are they? _______________________________________

41. Do you feel that you need to straighten out the current relationship? ____

42. What kind of person is your significant other? ________________________

43. How long did you know them before you entered the relationship? _______

44. What do you enjoy most about your relationship? ______________________

45. What is most difficult about your relationship? _______________________

46. If you have children, what are their names and ages? ___________________

47. Do any of them have illnesses or defects? ____ If so, list by child’s name: ___________________________________________________________________

48. Which child seems easiest to get along with and why? __________________

49. What child seems most difficult to get along with and why? ______________

50. Who disciplines the children and why? ________________________________

WORK HISTORY

51. What is your present work? ______________________ How long? _________

52. Did you choose the field you are in? __________________________________

53. List other previous work, how long you worked at it and why you quit. ______
__________________________________________________________________

54. How do people at your work treat you? _______________________________

55. Please describe any problem you have with either the people or the type of work at your present position. __________________________________________
___________________________________________________________________

FAMILY HISTORY

56. Is your father living? ___ How old is he? ___ Is your mother living? ___ How old is she? ___ If either parent is dead, then when and at what ages did they die and from what causes? __________________________________

57. What is/was your father’s education? _____________ Occupation? ________

58. What is/was your mother’s education? ____________ Occupation? _________

59. Do/did your parents have any illnesses or defects? ______________________

60. What is the name, age and occupation of each of your siblings? ___________
___________________________________________________________________

61. Who were you closest to as you grew up? _____________________________

62. Who gave you the most trouble as you grew up? _______________________

63. What nervous trouble or nervous breakdowns occurred in your family or relatives? ___________________________________________________________

64. What kind of person was/is your father? ______________________________

65. What kind of person was/is your mother? _____________________________

66. How did you get along with your parents? _____________________________

67. What’s the nicest thing your father ever did/said to you? ________________
___________________________________________________________________
68. What’s the worst thing your father ever did/said to you? _________________
___________________________________________________________________

69. What’s the nicest thing your mother ever did/said to you? ________________
___________________________________________________________________
70. What’s the worst thing your mother ever did/said to you? ________________
___________________________________________________________________
71. How did your parents get along? _____________________________________
72. What types of things did they argue about? ___________________________
73. How did they show affection to the children? __________________________

74. How did they show affection to each other? ___________________________

75. What outside activities did you family have? ___________________________

76. If you have a step-parent, give your age when your parent remarried. ______

77. If you were not brought up by your parents, who did bring you up and between what years? _________________________________________________

            Briefly describe this experience: ________________________________

            __________________________________________________________________

HEALTH HISTORY

78. Describe your health during childhood. ________________________________

79. Describe your health during adolescence. ______________________________

80. What is your height? __________  Your weight? ________________________

81. List any surgical operations? ________________________________________

82. When were you last examined by a doctor? ____________________________

83. Describe any accidents that required emergency medical attention. ________ 

___________________________________________________________________

84. List major illness in your history. ___________________________________

85. When you feel bad, what is the feeling you most often have? ____________

86. What aches, pains, or physical discomforts do you have? ________________

87. Do you have a family physician? _____ Name: _________________________

88. What have you been hospitalized for in the past? ______________________

89. What drugs have you used and for what? _____________________________

___________________________________________________________________

SEX HISTORY

90. Describe your parent’s attitudes toward sex. ___________________________

___________________________________________________________________

91. When and how did you acquire your first knowledge of sex? ______________

____________________________________________________________________

92. When did you first become aware of your own sexual impulses? ___________

93. Is your present sex life satisfactory? ___  Please explain: ________________

___________________________________________________________________

94. Describe sexual difficulties you have had (if any). ______________________
____________________________________________________________________

95. Describe any sexual issue that is important for your counselor to know that would assist in making your changes. ___________________________________

 

MONEY HISTORY

96. What did your parents teach you about money? ________________________

___________________________________________________________________

97. Who handles money in your present family? ___________ Is there difficulty in this arrangement? ___ If yes, what difficulty? ___________________________

98. Describe any money difficulties you have had or now have. _______________

___________________________________________________________________

PERSONAL HISTORY

99. What difficulties have you had with the law? _________________________

100. What is your main interest outside your work? _______________________

101. What club meetings or organizations do you attend? __________________

102. What is your religious affiliation? _________________ Do you attend services? ___

103. Describe your religious training. ___________________________________
__________________________________________________________________

104. What do you like most about yourself? ______________________________

105. What do you like least about yourself? _____________________________

106. Do you ever feel that something might be wrong with you? ____ If so, what? ______________________________________________________________
___________________________________________________________________

107. Who is your favorite character from the movies, TV or stories you’ve read or heard? ___________________________________________________________

108. What was your favorite fairy tale, story or movie when you were a kid? _________________________________________________________________
109. What in life do you feel best about? ______________________________

110. What in life do you feel worst about? _____________________________
111. If everything goes right, what do you imagine you might be doing in the next five years? ____________________________________________________

112. If everything goes wrong, what do you imagine you might be doing in the next five years? ____________________________________________________

113. How long do you think you might live? ______________________________
114. How do you suppose you might die? _______________________________

115. What would be “heaven on Earth” for you? __________________________

116. What about yourself do you most want to change? ___________________

117. What do you feel is your biggest problem? __________________________

118. What is your most unpleasant memory? _____________________________

119. What is your most pleasant memory? _______________________________

120. Please add any information not covered by this questionnaire that you want me to know. _______________________________________________________
__________________________________________________________________

121. On the back of this page and/or add pages, give a word picture of yourself as you would be described by:

            a). yourself

            b). by your spouse (if married)

            c). by your best friend

            d). by someone who dislikes you

122. On the back of a page describe the way you spend time on:

            a) a weekend day that does not include religious services.

            b). a typical work weekday.  If you are a stay at home parent use your work days.

Thank you for completing this form.