PREVIOUS COUNSELING HISTORY
Have you ever been treated by a psychiatrist, psychologist, licensed clinical social worker, or any other mental health worker?
Y N
If yes, please specify:
| Therapist's Name |
Dates |
Reasons |
For How Long |
Were You Satisfied? |
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Have you ever been hospitalized for psychiatric reasons? - Y N
If yes, please explain:
________________________________________________________________________
________________________________________________________________________
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FAMILY OF ORIGIN MEMBERS
Father:
If living, age: _________
If deceased, when and cause of death ________________________________________
Occupation ____________________________________________________________
Mother:
If living, age: _________
If deceased, when and cause of death _________________________________________
Occupation _____________________________________________________________
Have your parents ever divorced? - Y N
If yes, how old were you when they divorced? _________
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