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 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 If you answered “Yes” above, describe how you were hurt.
Describe your strengths, gifts, and resiliencies
Section 5 - Physical/Medical Information List important present or past illnesses or injuries: (Include all hospitalizations with dates)
Are you presently taking prescription medications? (Yes/No). If so, what medication, how much, and prescribing physician.
Do you smoke? (Yes/No) If so, how much? When did you start?
Do you drink alcohol? (Yes/No) If so, how much? When did you start?
Do you use other substances and if so what, how much, and how often? When did you start?
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?
Section 6 - Trauma / Loss Have you experienced a trauma that has effected you psychologically, physically, and/or sexually? (Yes/No). If yes, please explain.
Have you experienced a series of losses and/or grief? (Yes/No) If yes, please explain.
By signing my name in the box below, I authenticate that I have read, understand and agree to the terms of the Professional Disclosure Statement and Privacy Policy
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