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?
If they were divorced, what was your age at the time?
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?
Other spiritual concerns of which you'd like for me to be aware: Section 5 - Physical/Medical Information
Rate your physical health:
List important present or past illnesses or injuries: (Include any hospitalizations with dates) Your Regular (Primary Care) Physician, If different: 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? Name of Psychiatrist & Approximate Number of Sessions Name of Psychiatrist & Approximate Number of Sessions: Have you ever been treated or seen by another counselor? (Yes/No) If yes, when? Name of Counselor & Approximate Number of Sessions: Name of Counselor & Approximate Number of Sessions: Submit