Lifestyle Assessment - Counseling
Name:
Date:
__________________________________________________________________________________________
PERSONAL HISTORY
Where were you born?
Where were you raised?
What was the last grade you completed?
What are your hobbies or most enjoyable activities?
Military History: _____________________________________________________
Faith System:
Describe your spiritual life:
How often do you attend a place of worship?
Are you actively involved in church
Yes
Are you open to prayer in our sessions?
Never
Seldom
Often
All the time
No What church do you attend:
Yes
No
Would you be interested in learning how to grow spiritually?
Yes
No
Which of the following applied to you during your childhood and adolescence?
Happy childhood
Emotional problems
Eating disorder
Unhappy childhood
Sexually abused
Behavior problems
Family problems
Physically abused
Alcohol/Drug abuse
Financial problems
Legal trouble
Academic/school problems
Number of brothers:
Do you have step-
Number of sisters:
Father
Birth order (Bio):
Other (Please explain):
# of Step Siblings:
Mother? How close are you to your family of origin?
FINANCIAL HEALTH
After your bills are paid do you usually have a surplus left, break even or are you in the hole?
Do you have a consistent savings plan? Yes
No
Is your debt under control? Yes
No
Do you have an investment strategy? Yes
No
Are you satisfied with your retirement plans? Yes
No
When do you plan to retire?
How much monthly income will you need in retirement?
How much will you need to
save monthly to reach this goal?
How will you decrease your expenses or increase your income to reach this goal?
Have you ever been in counseling before?
Yes
No With whom?
What dates?
What was the outcome?
How would you want this experience to be different?
History of mental health problems: _____________________________________________________
Other physical/emotional/behavioral/medical problems: _____________________________________________________
Have you recently thought of hurting yourself (suicide)?
Have you recently thought of hurting someone else?
Have you ever heard voices or seen things other people weren’t seeing?
Have you ever felt that your mind wasn’t working right?
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MENTAL HEALTH HISTORY (Skip this section if you don’t have any mental health or relationship issues)
Do you have or have you had problems in any of the following areas? (Check all that apply)
Current
Current
Past
Current
Past
Current
Past
Anxiety
Abortion
Anger
Appetite
Ambition
Aggressive
behavior
Abusive
relationship
Acting
impulsively
Can’t keep
a job
Concentration
difficulties
Crying
Children
Problems
Compulsion
or
obsession
Career
problems
Difficulty
making
decisions
Drinking too
much
Drug
problems
Depression
Divorce
Evil thoughts
Eating
problems
Fear
Family
problems
Friend Issues
Financial
problems
Guilt
Headaches
Inferiority
feelings
Insomnia
Lazy
Loss of
control
Lonely
Legal problems
Marital
difficulties
Memory
Mental illness
Nervous tic
Nervousness
Overeating
Odd behavior
Outbursts
of temper
Parenting
problems
Phobic
avoidance
Procrastinating
School
problems
Sexual
problems
Stomach
problems
Stressed out
Strange or
unusual
sensations
Shyness
Tiredness/Less
Energy
Unhappiness
Unusual
physical
symptoms
Work
dissatisfaction
Taking too
many risks
Working too
hard
Suicide
attempts
Vomiting
Withdrawal
Difficulty
Trusting Others
Sleep
disturbance
Victim of a
crime
Multiple
broken
relationships
Domestic
Violence
Past
MARITAL/PRE-MARITAL HISTORY (Skip this section if you are not seeking help for relationship issues)
On a scale from 1-10, 10 being the greatest, how would you rate your overall satisfaction with your relationship?
Are you having an affair?
Yes
No Is your partner having an affair?
Yes
No How many affairs (emotional and/or sexual)
have you had in this relationship?
Lifestyle Therapy & Coaching 1101 McMurtrie Drive NW Suite C4 Huntsville, AL 35806 www.LifestyleTherapyCoach.com Page 2
Do you have current or past involvement in pornography
, homosexuality
, or other deviant sexual behavior
?
PROBLEM DESCRIPTION (This will help the clinician understand the scope of your problem.)
Please state in your own words the nature of your main problem(s) and why you are seeking help:
Please provide some background information about your problem:
Significant personal and family history that may give light on the problem:
How upset are you right now about your problem(s)?
Mildly
Moderately
Very
Extremely
Totally; please explain:
Give approximate dates and events surrounding the beginning of your problem(s):
What are some of the agencies or outside people involved in your problem?
What are some of the things you have done to try to resolve this problem?
What are some of your greatest strengths that can help you with this problem?
What are some of your greatest weaknesses contributing to this problem?
EXPECTATIONS REGARDING TREATMENT
What do you hope to get out of coming to treatment? What do you hope to accomplish?
Who will be the first to notice you are feeling better?
How will you know you are feeling better?
What will you do when you are feeling good?
What do you expect treatment to be like?
How long do you think you will be in treatment?
Thank you for completing this questionnaire. You may email it to mailto:admin@lifestyletherapycoach.com, fax to (888) 502-0641 or
bring it in with you when you come. If you have any questions regarding your appointment or to get directions call (256) 850-4426.
We are located off of University Drive on the same street as the Burger King beside the Target Shopping Center in NW Huntsville
down near the intersection of Moore Farm Lane.
Remember you can manage your appointments at appointment.LifestyleTherapyCoach.com.
We look forward to providing you excellent services. And we hope you will let your friends know about us!
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