Individual Questionnaire | Relationship Center of South Florida

Your Name(Required)

Your Email(Required)

Please use ONE word only to describe:

You

Your mother

Your father

Your significant other

In ONE sentence, please describe:

Your childhood

Your earliest memory from childhood

Your relationship with brothers & sisters

Please list all members of your FAMILY OF ORIGIN - including parents, stepparents, sisters and brothers, and any others who lived with you growing up. Also include any very significant person (like a grandparent, aunt, or uncle) who had a major impact on your life.

Biological mother

Biological father

Significant person (like a grandparent, aunt, or uncle)

Person of significance

Please list all members of your CURRENT family - including spouse or partner, children and stepchildren, and any other extended family members or friends who live with you. Please indicate their current age and date of marriage or partnership.

Current family

Indicate any prior marriages or partnerships with applicable dates

Why did you decide to start therapy at this particular point in time?

What will be different in your life when you complete therapy?

Please indicate any current medical problems and prescribed medications

Please list dates of all prior experiences with therapy/counseling, psychiatrists, psychiatric hospitalization, and/or residential rehab.

Please indicate current use of alcohol or other drugs, and any treatment or 12 step program experience

What I like the most about my life right now is

These days I am mostly feeling (select one or two):

MAD

SAD

GLAD

ASHAMED

AFRAID

This is how I cope with stress in my life

This is how I avoid dealing with problems in my life

What I want to ask my therapist is

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