Letter Agreement For Provision Of Counselling Services Page 3
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512. What are your goals for counselling? ______________________________________________________________________
_____________________________________________________________________________________________________
13. How strongly do you want counselling for your problem?
Very Strongly
Strongly
Moderately
Could do Without
14. Suppose someone who used to know you well, but has not seen you for some time sees you when you complete
counselling.
What would be different about you then than now?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
15. When you are successful, what will you be doing differently? ____________________________________________________
_____________________________________________________________________________________________________
16. Are you seeing a counsellor anywhere else now?
___Yes
___No
17. Has there been any history of alcohol ___ or drug ___ abuse in your family? Are they presently recovering? Yes
No
___Father
___Mother
___Spouse
___Children
___Self
18. Doctor’s Name: ______________________ Medications & Frequency: ___________________________________________
If we may contact your doctor regarding your involvement in counselling, please SIGN here: ______________________
19. Briefly describe the type of person your mother (or stepmother or person who substituted for your mother) was when you were a
child and how you got along with her: ______________________________________________________________________
_____________________________________________________________________________________________________
Mother's age: __________
Mother’s occupation: ____________________ Mother’s Religion: ____________________
If deceased, how old were you when she died? __________
20. Briefly describe the type of person your father (or stepfather or person who substituted for your father) was when you were a
child and how you got along with him: _________________________________________________________________
_____________________________________________________________________________________________________
Father's age: __________
Father’s occupation: ____________________ Father’s Religion: ____________________
If deceased, how old were you when he died? __________
21. If your mother and father separated, how old were you at the time? _____________
22. Total number of times mother divorced ________ Total number of times father divorced ________
23. I was child number ______ in a family of ______ children.
Adopted: ______ Yes______ No
24. Describe
any
unusually
disturbing
features
in
your
relationship
to
any
of
your
brothers
or
sisters:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
25. Number of close male relatives who have been emotionally disturbed:
_______
Number that have been hospitalized for psychiatric treatment, or have attempted suicide:
_______
Number of close female relatives who have been emotionally disturbed:
_______
Number that have been hospitalized for psychiatric treatment, or have attempted suicide:
_______
Last updated 1/25/2007
C:ppcshareFormsBiographical Information Form.DOC
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