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Cathy Weeg New Client Questionnaire
Cathy Weeg, LPC
Counseling and Therapy Services
Biographical Information
Personal and Relationship Information
Client Name:
First
Last
Today's Date:
MM slash DD slash YYYY
Date of Birth:
MM slash DD slash YYYY
Education Level (Check any that apply)
GED
High School Diploma
Some college/training
College Graduate
Graduate School
Post Graduate
Technical/Vocational School
Additional Degrees/Certificates:
What occupation(s) have you mainly been trained for?
Present Occupation Title:
Client Occupation Status:
Full-Time
Part-Time
Briefly describe your satisfaction with your job:
Names and ages of child or children:
Briefly describe your relationship with your child or children:
Present Relationship Status:
Number of years in current relationship:
Briefly describe your relationship with your Spouse/Significant Other:
Briefly describe your satisfaction with friendships:
Religious/spiritual beliefs:
Cultural Background:
Family History
Mother's age:
If deceased, how old were you when she died?
Briefly describe the type of person your mother (or stepmother or mother substitute) was when you were a child and how you got along with her:
Father's age:
If deceased, how old were you when he died?
Briefly describe the type of person your father (or stepfather or father substitute) was when you were a child and how you got along with him:
If your mother and father divorced/ended their relationship, how old were you at the time?
If your mother and father did not raise you when you were young, who did?
Were you adopted?
Yes
No
Names and ages of living brothers (if any):
Names and ages of living sisters (if any):
Were there any unusual events or disturbing features growing up or currently with your family that you wish to share? Briefly describe:
Treatment History
Approximate dates and names of previous mental health providers:
If you had previous providers what was effective about the treatment and what was not effective?
Are you currently taking psychiatric medication?
Yes
No
If yes, please list the medication and prescriber:
List your chief physical ailments, diseases, complaints, or handicaps:
Primary Care provider's name:
Personal Evaluation
Briefly list your present primary complaints, symptoms, and problems:
Under what conditions are your problems worse?
Under what conditions are they improved?
List the things you enjoy doing the most, the kinds of things or persons that give you pleasure:
List your main positive traits:
List your main negative traits:
List your main social difficulties:
List your main school or work difficulties:
List your main life goals:
Additional information that you think might be helpful:
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