Section 1 - Personal & Relationship Information LIST UP TO 3 PREVIOUS RELATIONSHIP(S) WITH APPROXIMATE DATES FOR THE FOLLOWING CATEGORIES - MET, LIVING TOGETHER, MARRIED, SEPARATED, DIVORCED, DEATH (Enter all that apply & label accordingly): Children (Name, DOB, Living (Yes/No), Age, Sex, Marital Status, School or City): Section 2 - What Brings You to Bridgepath? PLEASE BRIEFLY DESCRIBE YOUR REASON(S) FOR SEEKING HELP AND WHAT YOU WOULD LIKE TO SEE HAPPEN AS A RESULT OF YOUR EXPERIENCES HERE. PLACE A CHECK BY ANYTHING BELOW YOU HAVE EXPERIENCED WITHIN THE PAST 3 MONTHS: PLEASE LIST ANY SIGNIFICANT LOSSES AND/OR TRAUMAS AND ANY RECENT MAJOR TRANSITIONS WITH DATES IS THERE ANYTHING ELSE THAT WOULD BE HELPFUL FOR ME TO KNOW? Section 3 - Family History FAMILY OF ORIGIN: (Complete this section about the persons you think of as your:) FATHER MOTHER
Are your birth parents happy together?
What would you rate your parents' marriage as...
Would you rate your childhood life as...
As a child, did you feel closer to...
List your brothers and sisters in birth order. Please also include the following information: Name, Age, Sex, Living (Yes/No), Marital Status ( S, M, W, D), Current City of Residence: Section 4 - Faith/ Spiritual Background
Active in a place of worship?
Change in religious affiliation?
Have you ever felt betrayed or seriously hurt by a pastor or other religous leader?
Section 5 - Physical/Medical Information
Rate your physical health:
List important present or past illnesses or injuries: (Include any hospitalizations with dates) Are you presently taking prescription medication? (Yes/No) If so, what medication and how much? Do you smoke? (Yes/No) If so, how much? Do you drink alcohol? (Yes/No) If so, how much? Do you use other substances and if so what, how much, and how often? Self Care (Hobbies, Exercise, Ect.): Have you ever been treated or seen by a psychiatrist? (Yes/No) If yes, when? Have you ever been treated or seen by another counselor? (Yes/No) If yes, when? Submit