Family History: List your birth family: Parents, siblings and
their ages, where you fit into the birth order including how many miscarriages or stillborn(s) your
mother had. Include additional information about step parents and/or step or half siblings if
applicable. If you have experienced foster care or orphanage system situations.
Current
Family: Your personal family info, married, single, divorced, how many
children.
Living
Situation: Relevant living conditions such as working, going to school, retired,
dependent.
Major Traumas In your
life: deaths, divorces, accidents, abuses, or a memory you feel had a negative impact on
your life.
Briefly list two or
three reasons why you are coming to therapy or what you hope to
accomplish.
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