Social History Questionnaire - Corner Canyon Counseling

1 Social History Questionnaire Patient's Name_____Date_____. FAMILY History . Date of Birth_____Place of Birth_____. Primary city (or cities) of residence during childhood and adolescence_____. _____. _____. Natural Father's Name_____. Is he living?_____. His Place of Employment_____. Please describe your father_____. _____. _____. Described your relationship with your father_____. _____. _____. _____. Natural Mother's Name_____. Is she living?_____. Her Place of Employment_____. Please describe your mother_____. _____. _____. _____. Describe your relationship with your mother_____. _____. _____. Social History Questionnaire Page 2. Patient's Name_____. List any step-parents and their relationship to you_____. _____. _____. List your brothers, sisters and yourself, from oldest to youngest (include ages): Oldest_____ 5th_____. 2nd_____ 6th_____. 3rd_____ 7th_____. 4th_____ 8th_____. List additional siblings on the back and check here to note that listing____.

2 Were you abused growing up?_____. Sexually____Physically____Emotionally___ __Medically_____. If yes, by whom_____. Was your family of origin subject to Death_____Separation_____Divorce____Othe r trauma_____. If you answered yes to one of the above, please explain the circumstances and your age when these events occurred. Use the back of the page if you need additional writing space. _____. _____. _____. _____. _____. _____. _____. How was discipline handled in your home as a child?_____. _____. _____. _____. How were you impacted by your family of origin?_____. _____. _____. _____. _____. _____. _____. Social History Questionnaire Page 3. Patient's Name_____. INTERPERSONAL History . Please list your partners/spouses and your age when you were in the relationship(s): _____. _____. _____. Overall, how would you describe your relationship with your current partner/spouse: _____. _____. Partner/Spouse's place of employment:_____.

3 List any children from oldest to youngest. Include their ages. Oldest_____ 5th_____. 2nd_____ 6th_____. 3rd_____ 7th_____. 4th_____ 8th_____. List any additional children on the back and check here to note that listing____. EDUCATIONAL History . Last grade completed:_____. Where did you attend school:_____. What were your normal grades in school:_____. Did you have: Many friends____Few Friends____1 or 2 friends____No friends____. If you attended college, what did you major in?_____. Did you do well academically?_____. If you did not attend college, what did you do after high school?_____. _____. OCCUPATIONAL AND/OR MILITARY History . When did you begin working and what type of jobs have you held? _____. _____. _____. Social History Questionnaire Page 4. Patient's Name_____. What is your current occupation?_____. How long have your worked at your present job?_____. Are you satisfied with your present job?_____. If not, what is the cause of your dissatisfaction?

4 _____. _____. Are you a veteran?_____ If so, what branch of service_____. Date of discharge_____ Were you involved in combat?_____. SOCIO-CULTURAL History . How would you rate the financial status of your childhood home?_____. Were you raised in an urban____suburban____ or rural____ area? Did you have a strong support group of friends when you were growing up?_____. How would you describe your current financial status?_____. Is your present home urban____suburban____ or rural____? What role did religion play in your family of origin?_____. _____. _____. _____. What is your religious preference?_____. Are you active in your religion?_____. To which racial or ethnic group do you primarily identify?_____. MEDICAL History . What major illnesses have you had or do you have at the present time? _____. _____. LEGAL History . Have you ever been convicted of any criminal offense?_____. If yes, of what offense and when?_____. Are you currently involved with any legal issue?

5 _____. If yes, what?_____. Social History Questionnaire Page 5. Patient's Name_____. SUBSTANCE ABUSE History . Have any of your family members had problems with alcohol and/or drug abuse?_____. Please describe who, their relationship to you, and the substances they _____. _____. Please describe your alcohol and/or drug use, past and present. Specify frequency and type of substance used. _____. _____. _____. Have you ever received treatment for substance abuse?_____ If so, when and where was this treatment given?_____. _____. _____. SEXUAL History . Have you ever engaged in sexual intercourse?____. If yes, at what age did you first engage in sexual intercourse?_____. How satisfied are you with the quality of your current sexual activity?_____. _____. What is your sexual orientation?_____. PERSONAL AND THERAPEUTIC GOALS. Immediate Goals _____. _____. _____. _____. Intermediate Goals (3 6 months). _____. _____. _____. _____. Long Term Goals (1 5 years).

6 _____. _____. _____. _____. Values _____. _____. _____. _____. Beliefs _____. _____. _____. _____. Fears _____. _____. _____. _____. Support System _____. _____. _____. _____. 248 East 13800 South, Suite 4, Draper, UT 84020 Phone: Fax.