___________ ___________ ___ Length of time: Length of time: Total number of marriages: ____ ____ ____ Assessment of current relationship (if applicable): Good Fair Poor ____ ____ ________ Parents legally married Mother remarried: Number of times: ____ ____ ________ Parents have ever been separated Father remarried: Number of times: ____ Parents ever divorced Special circumstances (e.g., raised by person other than parents, information about spouse/children not living with you, etc.): __Yes ___ Are there special, unusual, or traumatic circumstances that affected your development? No If Yes, please describe: ____ ____ Has there been history of child abuse? Yes No ____ ____ ____ If Yes, which type(s)? Sexual Physical Verbal ____ ____ If Yes, the abuse was as a: Victim Perpetrator ____ ____ ____ ______ Other childhood issues: Neglect Inadequate nutrition Other (please specify): Comments re: childhood development: Check how you generally get along with other people: (check all that apply) ____ ____ ____ ____ ____ Affectionate Aggressive Avoidant Fight/argue often Follower ____ ____ ____ ____ ____ Friendly Leader Outgoing Shy/withdrawn Submissive ____ Other (specify): _________________ Sexual orientation: Comments: ____ ____ Sexual dysfunctions? Yes No If Yes, describe: ____ ____ Any current or history of being as sexual perpetrator? Yes No To which cultural or ethnic group, if any, do you belong? ____ ____ Are you experiencing any problems due to cultural or ethnic issues? Yes No If Yes, describe: Other cultural/ethnic information:
Length of time: ___________ Length of time: ___________ Total number of marriages: ___ Assessment of current relationship (if applicable): ____ Good ____ Fair ____ Poor ____ Parents legally married ____ Mother remarried: Number of times: ________ ____ Parents have ever been separated ____ Father remarried: Number of times: ________ ____ Parents ever divorced Special circumstances (e.g., raised by person other than parents, information about spouse/children not living with you, etc.): Are there special, unusual, or traumatic circumstances that affected your development? __Yes ___ No If Yes, please describe: Has there been history of child abuse? ____ Yes ____ No If Yes, which type(s)? ____ Sexual ____ Physical ____ Verbal If Yes, the abuse was as a: ____ Victim ____ Perpetrator Other childhood issues: ____ Neglect ____ Inadequate nutrition ____ Other (please specify): ______ Comments re: childhood development: Check how you generally get along with other people: (check all that apply) ____ Affectionate ____ Aggressive ____ Avoidant ____ Fight/argue often ____ Follower ____ Friendly ____ Leader ____ Outgoing ____ Shy/withdrawn ____ Submissive ____ Other (specify): Sexual orientation: _________________ Comments: Sexual dysfunctions? ____ Yes ____ No If Yes, describe: Any current or history of being as sexual perpetrator? ____ Yes ____ No To which cultural or ethnic group, if any, do you belong? Are you experiencing any problems due to cultural or ethnic issues? ____ Yes ____ No If Yes, describe: Other cultural/ethnic information:
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