Name *

First Name

Last Name

Today's date *

MM

DD

YYYY

Have you received counseling before?

Yes

No

Are you taking any prescribed medications?

Yes

No

Do you have trouble sleeping?

Yes

No

Do you have trouble with your appetite?

Yes

No

Spouse's name

First Name

Last Name

Date of marriage

MM

DD

YYYY

Have you and your spouse ever separated?

Yes

No

Have you or your spouse filed for divorce?

Yes

No

Have you been married before your current marriage?

Yes

No

Describe your home situation growing up.

Father and mother in the home

Two parents in the home

Single parent in the home

Divorced

Other

What qualities were present in your home growing up?

Select all that apply.

Authoritarian: a parent made all the decisions, no discussions

Perfectionism: a parent expected perfect behavior

Critical: a parent always highlighted the bad, never the good

Abusive: physically, emotionally, or sexually

Addiction: a parent abused a substance or activity

Affectionate: a parent regularly said "I love you"

Religious: a parent attended church at least twice a month

Do you consider yourself a Christian?

Yes

No

Please select the three words that describe you most accurately.

Assertive

Passive

Fearful

Impatient

Optimistic

Pessimistic

Angry

Lonely

Self-critical

Shy

Anxious

Impulsive

Depressed

Moody

Serious

Laidback

Sensitive

Other