Biographical Information

BIOGRAPHICAL INFORMATION
Please fill out this biographical background sheet as completely as possible. It will help me in
our work together. All information is confidential as stated in the Counseling Agreement Form.
If you do not desire to answer a particular question, please indicate it on the form. Please bring
this package, signed and filled out, to your next session.
Name: _________________________________________ male/female __________

Address: _____________________________________________________________
Phone: h ___________________ w ___________________ c __________________
DOB: ______________ Place of Birth: ___________________________________
Person & phone# to call in emergency: ____________________________________
______________________________________________________________________
Occupation/Employer: __________________________________________________
Relationship Status/Living Arrangement: __________________________________
Significant Past Relationships:_____________________________________________
_______________________________________________________________________
Children (incl. Step- or grand-): ____________________________________________
_____________________________________________________________
Referral Source: ________________________________________________________
Presenting Problem(s) (be as specific as possible: time it started; how it affects you or others
around you; etc.): ___________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Estimated Severity of ….
Problem 1: mild _____ moderate _____ severe ____
Problem 2: _____ _____ _____
Problem 3: _____ _____ _____
Medical Doctor(s) (name & phone#):_________________________________________

_____________________________________________________________
_____________________________________________________________
Past/Present Medical Care (major medical problems, surgeries, accidents, falls,
illness):_________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
Specify all MEDICATIONS you are presently taking and for what. PLEASE PRINT
clearly:__________________________________________________________
__________________________________________________________________
________________________________________________________
_____________________________________________________________
Family History (give name/age or date of death, occupation, and a brief description of the
nature of your relationship when you were a child and as an adult):
Mother:____________________________________________________________
__________________________________________________________________
__________________________________________________________________
______________________________________________
Father:_____________________________________________________________
__________________________________________________________________
__________________________________________________________________
______________________________________________
Other Caregivers:________________________________________________________
__________________________________________________________________
__________________________________________________________________
___________________________________________________
Siblings:____________________________________________________________
__________________________________________________________________
__________________________________________________________________
______________________________________________
Family Medical History (Describe any illness that runs in the family: cancer, epilepsy,
etc):___________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Drug/Alcohol/Other Addiction History:

Parents/
Caregivers:__________________________________________________________
__________________________________________________________________
_____________________________________________
_____________________________________________________________
Self (If no personal history with drugs or alcohol, what is your current consumption):
__________________________________________________________________
__________________________________________________________________
___________________________________________________
Suicide Attempts or Self-Harming Behaviors (describe ages, reasons, circumstances, how,

etc):________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________
Friendships, Community, & Spirituality (describe the quality, frequency, type of activities,
etc.):___________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Past/Present Psychotherapies (give time frames, name, degree, phone & address, initial reason
for therapy, medication, brief description of the relationship and how helpful it was, and how/
why it ended):
1. ____________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
2. ____________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
What gives you most joy or pleasure in your life: ____________________________________

_____________________________________________________________________________________________
_______________________________________________________________________________
What are your main worries and fears:_________________________________

_____________________________________________________________________________________________
_______________________________________________________________________________
What are your most important hopes or dreams: ___________________________________

_____________________________________________________________________________________________
_______________________________________________________________________________

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BIOGRAPHICAL INFORMATION

Name: _______________________________ male/female

Referral Source: ________________________________________________________

Medical Doctor(s) (name & phone#):_________________________________________

Drug/Alcohol/Other Addiction History:

Suicide Attempts or Self-Harming Behaviors (describe ages, reasons, circumstances, how,

What gives you most joy or pleasure in your life: ____________________________________

What are your main worries and fears:_________________________________

What are your most important hopes or dreams: ___________________________________

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