This inventory will help your counsellor serve you more efficiently and effectively. As this is a general form (to cover as many cases and situations as possible), some of the questions included may not be relevant to you. Please answer each relevant question as thoroughly as possible. If a question is not applicable to you, please write N/A rather than leaving it blank. It is best that you do not ask your spouse, relatives or friends for assistance. If you want their opinion, you can give them a separate copy to fill out, and you may keep all versions to explore and discuss significant discrepancies. If you need any help with this form, you may ask your counsellor.
All material contained in this inventory is confidential. However, if you feel uncomfortable answering any question, you may skip it. As an alternative, some customers lend this inventory to the counsellor for a couple of weeks, or only during sessions, but take it home afterwards. Other customers photocopy the form and keep a complete copy for themselves, giving the counsellor a copy that only contains the information they are comfortable to reveal at that time. You are completely in charge of the content and use of this form.
Required personal information:
- Date (when completing this inventory): _____________
- Your Name: ___________________________________
- Date of birth: __________________________________
- Address:______________________________________
________________________________ zip __________
- Phone: (home) _______________ (work)____________ (cell) _________________________________________
May we leave messages at home? __work?__cell?__
- Preferred schedule for your serssions: _____________ _____________________________________________ Definitely unavailable time(s) _____________________ _____________________________________________
- Doctor: _____________________________Tel._______ Health Care #: _________________________________
- Social Worker: _______________________Tel._______
- Occupation: ___________________________________
- Education: ____________________________________
- Religion: ______________________________________
- Ethnic background: _____________________________ First language: _________________________________
- Who do you have for support? (If you want us to contact your support, please give the name & phone #.)
Former Counsellor: ___________________Tel._______
Church/Temple/etc.: ____________________________
Minister/Spiritual leader: _______________Tel._______
Nearest relative's name _________________________ Relation to you______________________Tel.________
Friends: ______________________________________
______________________________________________ Other(s): ______________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
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COMPENSATION
& COST COVERAGE:
If you have a benefits package through your employer, it is most likely that you have up to six sessions free, through an Employee Assistance Program.
If you have extended health benefits, you may be covered for a number of sessions. Please contact us to explore this further.
If your current need for counselling/therapy
is a result of being a victim of crime, work injury or motorvehicle accident, your cost may be covered by a government compensation agency or insurance company.
Please describe the incident: ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________
If you are First Nations/Metis/etc., you may be eligible for compensation and/or therapy coverage through your band.
Native Status #(if applicable): ___________________
Your Band’s Name: ___________________________
Band’s Address: _____________________________
__________________________________ zip ______
Tel. _________________ Fax ___________________
Toll Free Number: 1-8_ _-_ _ _-_ _ _ _
- Who referred you to counselling? ____________________________________________
- For what reason? ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________
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B. FAMILY BACKGROUND and HISTORY
B.1 FAMILY COMPOSITION (This will help your counsellor draw your family tree, which is also called “genogram”)
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Name |
Sex
M/F |
Date of Birth |
Marital Status |
Occupation |
Alcohol, Drugs, Suicide, Crime, Bankruptcy, etc |
Quality of Relationship With You (good/bad, close/distant, supportive/abusive, etc.) |
Yourself |
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Partner |
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Father |
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Mother |
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StepF. |
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StepM. |
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F-in-low |
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M-in-low |
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Sibling |
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Other |
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Other |
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Other |
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B.2 Before birth and during your childhood, did any of the following happen to you? (Please put a check mark for all that apply.)
_____I was an unwanted baby
_____my parents explored abortion
_____my mom was ambivalent about keeping me or not.
_____
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_____born with a health problem
_____colicky baby
_____separated from mom/caregiver
_____repeated ear infections
_____unexperienced parents
_____drug/alcohol dependent parents
_____frequent moves
_____witnessed violence
_____frequent conflicts between parents
_____abuse
_____neglect
_____
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B.3 Was there any major loses and deaths in your immediate or extended family? Yes/No
If yes, please comment on the loss/death, cause, and time: _____________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
B.4 Have you or anyone in your extended family experienced any of the following?
EXPERIENCE |
Person’s
Relation to You |
Comments |
Schizophrenia |
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Depression |
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Mood Swings |
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Anxiety / Panic Attacks |
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Suicide or Attempts |
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Sexual Abuse |
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Physical Abuse |
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Alcohol Abuse |
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Drug Abuse |
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Overeating |
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Anorexia or Bulimia |
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Imprisonment |
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Learning Disability |
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Attention Deficit |
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Mental Retardation |
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Dementia / Brain Damage |
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B.5 Your romantic/marital history (please, circle all that apply): Married, Remarried, Engaged, Common-low, Never-married, Widowed, Separated, Divorced, other: ______________________________________________________________________
The approximate dates when you: started your first dating ____________
/got engaged ___________, /got married ___________, /started living common-low ___________, /separated ____________, /divorced ___________, /became widowed ___________, /started dating again ______________, /remarried______________, /divorced (2) ___________, /remarried (2) ___________, /other__________ ___________, /other__________ ___________, /other__________ ___________, /other__________ ___________, /other__________ ___________,
B.6 If you currently have a partner, has either of you been in a previous relationship? YOU: Yes/No PARTNER: Yes/No
Please answer as accurately as you can about yourself and your partner (do your best, without asking your partner for information):
YOU: PARTNER:
Age at first relationship: _______________________________
Age at termination of first relationship: ___________________
Cause of termination of first relationship __________________
___________________________________________________
How many relationships did you have until now? ___________
Causes of termination: ________________________________
___________________________________________________
___________________________________________________
Time alone prior to current relationship: __________________
What did you first find attractive about your current partner?
___________________________________________________
List three things you like about your partner : _____________
___________________________________________________
___________________________________________________
___________________________________________________
List two things you don’t like about your partner: __________
___________________________________________________
___________________________________________________
___________________________________________________
If you had a choice, how would you like your partner to be
different? __________________________________________
___________________________________________________
___________________________________________________
___________________________________________________ |
Age at first relationship: _______________________________
Age at termination of first relationship: ___________________
Cause of termination of first relationship __________________
___________________________________________________
How many relationships did he/she have until now? ________
Causes of termination: ________________________________
___________________________________________________
___________________________________________________
Time alone prior to current relationship: __________________
What did your partner first find attractive about you?
___________________________________________________
List three things your partner likes about you: _____________
___________________________________________________
___________________________________________________
___________________________________________________
List two things your partner doesn’t like about you: ________
___________________________________________________
___________________________________________________
___________________________________________________
If your partner had a choice, how would he/she like you to be different? __________________________________________
___________________________________________________
___________________________________________________
___________________________________________________ |
B.7 If need be, would your partner or other family members be willing to come into therapy sessions? Yes/No
Please, explain your answer: ______________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
PERSONAL DATA
C.1 Please check all that are a present concern or problem:
_____no energy
_____cannot enjoy life
_____memory problems
_____anxiety
_____fatigue
_____anger outbursts
_____shortness of breath
_____sweating
_____hot flashes
_____reliving past event
_____no loving feelings
_____fears
_____chest pains
_____decision difficulty
_____racing thoughts
_____foolish business investments
_____hard to make friends
_____work problems
_____out of control behaviour
_____taking painkillers often
_____mood swings
_____unusual experiences
_____physical numbness |
_____insomnia
_____disturbing memories
_____low self-esteem
_____poor appetite
_____headaches
_____nightmares
_____heart palpitations
_____clammy hands
_____getting startled easily
_____flashbacks
_____hopeless feelings
_____sexual difficulties
_____suicidal thoughts
_____overly confident
_____distractibility
_____sexual indiscretions
_____socially withdrawn
_____eating disorder
_____drinking alcohol
_____seeing things
_____excess energy
_____unsure of reality
_____wish to die |
_____depressed
_____guilt feelings
_____poor concentration
_____overeating
_____dizziness
_____unwanted thoughts
_____racing heart
_____stomach problems
_____sleeping too much
_____always on guard
_____apathetic
_____numbing out
_____distrustful
_____pressured speech
_____buying sprees
_____high risk activities
_____family arguments
_____often physically sick
_____hearing voices
_____losing track of time
_____slowed thinking
_____physical violence
_____unsure of identity |
C.2 Please, describe your major concerns or problems in the present. Do not focus on the checklist above. If you need more space,
you may use a separate sheet. ___________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
- C.3 Did you have these concerns or problems in the past? Yes/No If yes, please, explain.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
C.4 What persons, situations, activities, etc. seem to “trigger” these problems, or make them worse?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
C.5 Have you ever received counselling or psychological help before? Yes/ No. If yes, when? ___________
Where? ________________________________________________________________________________________________
What was done? ________________________________________________________________________________________
What results? __________________________________________________________________________________________
C.6 Have you ever taken medication for emotional problems? If so, please explain:
What problems? _________________________________________________________________________________________
What medication? _______________________________________________________________________________________
When? __________________________________________ For how long? __________________________________________
C.7 What do you like? Around what persons, things, situations or activities do you feel genuine pleasure?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
C.8 Around what persons, things, situations or activities are you likely to feel extremely angry, depressed, guilty, or anxious?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
C.9 How does faith and spiritual life affect (either positively or negatively) the difficulties you are experiencing?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
C.10 Have you had physical pains in the past? Yes/No If yes, please describe what pains and how frequent?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
C.11 Are you presently under a physician’s care for physical problems? Yes/No If yes, what problems?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Please, list medication: ___________________________________________________________________________________
_______________________________________________________________________________________________________
C.12 Have you ever been (are you now being) treated for any type of chemical dependency abuse? Yes/No
If yes, what were you using? ______________________________________________________________________________
When were you treated? ____________________ Where? ______________________________________________________
By whom? __________________________________ For how long? _______________________________________________
Results:________________________________________________________________________________________________
_______________________________________________________________________________________________________
C.13 Are you at the present time using any type of chemical substances? Yes/No If yes, please indicate what you are using: _______________________________________________________________________________
_______________________________________________________________________________________________________
How frequent do you use these substances? __________________________________________________________________
C.14 Have you ever been convicted or charged for criminal activity? Yes/No If yes, what was the conviction/charge ?_________________________________________________________________________When? ________
Consequences: __________________________________________________________________________________________
C.15 Are you being investigated in the present for any crime? Yes/No If yes, what are you being investigated for?___________________________________________________________________________________
What is the current stage of that investigation? _______________________________________________________________
______________________________________________________________________________________________________
WEEKLY EXPERIENCE RECORD
D.1 Indicate (by placing an “X” on the dotted line) the frequency of problems listed below, during the past week.
Rarely or Very Little --------------------------------------------------> Frequently or a Great Deal
- Anger or irritability >--------------------------------------------------------- > ------------------------------------------------------>
- Anxiety, worry or fear >--------------------------------------------------------- > ------------------------------------------------------->
- Guilt, self-condemnation >--------------------------------------------------------- > ------------------------------------------------------->
- Hopelessness, depression >--------------------------------------------------------- > ------------------------------------------------------->
- Loneliness >--------------------------------------------------------- > ------------------------------------------------------->
- Helplessness >--------------------------------------------------------- > ------------------------------------------------------->
- Thoughts of suicide >--------------------------------------------------------- > ------------------------------------------------------->
- Self-pity >--------------------------------------------------------- > ------------------------------------------------------->
- Inferiority, worthlessness >--------------------------------------------------------- > ------------------------------------------------------->
- Avoiding responsibility >--------------------------------------------------------- > ------------------------------------------------------->
- Being undisciplined >--------------------------------------------------------- > ------------------------------------------------------->
- Attacking others >--------------------------------------------------------- > ------------------------------------------------------->
- Overeating >--------------------------------------------------------- > ------------------------------------------------------->
- Over-smoking >--------------------------------------------------------- > ------------------------------------------------------->
- Sexual Problems >--------------------------------------------------------- > ------------------------------------------------------->
- Giving in to pressures >--------------------------------------------------------- > ------------------------------------------------------->
- Religious concerns >--------------------------------------------------------- > ------------------------------------------------------->
- Failure to achieve >--------------------------------------------------------- > ------------------------------------------------------->
- Other (specify) >--------------------------------------------------------- > ------------------------------------------------------->
- Other (specify) >--------------------------------------------------------- > ------------------------------------------------------->
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D.2 Would you describe your above responses as a “typical week”? Yes/No Please explain your answer:
________________________________________________________________________________________________ ____
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
IN CONCLUSION
E.1 My therapy goals are: (Please be specific describing what you wnat to see addressed or changed in your life through the upcoming sessions): ___________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
E.2 What I expect from therapy is (Please be specific): _____________________________________________________
_____________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
E.3 What I would like my counsellor to do is (Please be specific): _______________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
E.4 What I could do to help my counsellor help me is (Please be specific): _______________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Date: __________________________ Signature: _____________________________________________________________ |