Adult History Form 

Name _______________________________________________  Date ___________________

Address _____________________________________ City ___________________ Zip ____________

Phone _________________________ Date of Birth _____________________ SSN __________________

Email ________________________________________________________________________________

Emergency Contact _______________________________________ Phone _______________________

Problem Assessment 

What has led you to seek counseling at this time:______________________________________________ 
_____________________________________________________________________________________ 
_____________________________________________________________________________________ 
When did these problems develop:__________________________________________________________ 
_____________________________________________________________________________________ 

Suicidal/Homicidal Ideation: 
Have you attempted suicide:____Yes ____No If yes, how long ago was the last attempt: __________ 
Do you have current thoughts of ending your life: _____ Yes _____ No 
If yes, do you have a plan: ___________________________________________________________ 

Support System: 
Who can you count on for support: (please check all that apply) 
___ Parents ___ Spouse ___ Self Help Group ___Employer ___ Church 
___ Therapist ___ Neighbor ___ Extended Family ___ Close Friend ___ Pastor 
___ Siblings ___ Co-Worker ___ Medical Doctor ___ Other: ___________________________ 

Symptoms and Specific Problem Areas: (Please check any that are currently troubling you) 
___ Abortion/Adoption ___ Depression ___ Legal issues ___ Religion/Faith issues 
___ Addictions ___ Divorce ___ Loneliness ___ Separation 
___ Alcoholism ___ Eating disorder ___ Loss of appetite ___ Sexual abuse/rape 
___ Anger ___ Envy/Jealousy ___ Loss of control ___ Sexual addiction 
___ Anxiety ___ Family issues ___ Loss of concentration ___ Sexual issues 
___ Apathy ___ Father Issues ___ Loss of energy ___ Single parent 
___ Bitterness/resentment ___ Fear ___ Loss of memory ___ Singleness 
___ Burnout/stress ___ Finances/debt ___ Loss of sleep ___ Spouse abuse 
___ Change of lifestyle ___ Forgiveness ___ Loss of temper ___ Substance abuse 
___ Child abuse ___ Frustration ___ Loss of trust ___ Suicidal thoughts 
___ Children/discipline ___ Guilt ___ Marriage ___ Self-esteem 
___ Children/school ___ Health/medical ___ Medication/drug issues ___ Rejection 
___ Children/rebellion ___ Homosexuality ___ Mid-life ___ Unemployment 
___ Communication ___ Honesty ___ Mother issues ___Violence/rage 
___ Confusion ___ Infidelity ___ Panic attacks ___ Withdrawal 
___ Crisis/conflict ___ In-laws ___ Physical abuse ___ Worry 
___ Death of loved on ___ Job problems ___ PMS/hormones 
Marriage and Family 

Marital Status: ___ Single ___ Engaged ___ Married ___ Separated ___ Divorced 
How long divorced __________ Number of divorces _____ Length of current Marriage _____ 
Spouses name __________________________ Age _____ Occupation ______________________ 
Describe your relationship with your Spouse ___ Excellent ___ Good ___ Fair ___ Poor ___ N/A 
Describe your communication with your Spouse ___ Excellent ___ Good ___ Fair ___ Poor ___ N/A 

Please tell me about your children 

1) Name _______________ Age _____Sex _____ 2) Name ______________Age _____Sex _____ 
Biological Adopted Step Foster Relative Other Biological Adopted Step Foster Relative Other 
Does this child live with you __________ Does this child live with you __________ 
Physical disability? _____ Learning disability?____ Physical disability? _____ Learning disability?____ 
Describe your relationship with this child: Describe your relationship with this child: 
___ Excellent ___ Good ___ Fair ___ Poor ___ Excellent ___ Good ___ Fair ___ Poor 

3) Name _______________ Age _____Sex _____ 4) Name ______________ Age _____Sex _____ 
Biological Adopted Step Foster Relative Other Biological Adopted Step Foster Relative Other 
Does this child live with you __________ Does this child live with you __________ 
Physical disability? _____ Learning disability?____ Physical disability? _____ Learning disability?____ 
Describe your relationship with this child Describe your relationship with this child 
___ Excellent ___ Good ___ Fair ___ Poor ___ Excellent ___ Good ___ Fair ___ Poor 

Family History 
Mother: Living, age ______ Died at age ______ How old were you at her death?_______ 
Describe your relationship with your Mother ___ Excellent ___ Good ___ Fair ___ Poor ___ N/A Father : Living, age ______ Died at age ______ How old were you at his death?_______ Describe your relationship with your Father ___ Excellent ___ Good ___ Fair ___ Poor ___ N/A 
Describe their relationship: ___ Very happy ___ Happy ___ Ok ___ Unhappy ___ Very Unhappy ____N/A 
Were your parents divorced? ___ Yes ___ No How old were you?_______ 
Do you have stepparents? ___ Yes ___ No 
Describe your relationship with your Stepparents ___ Excellent ___ Good ___ Fair ___ Poor ___ N/A 
What was your birth order: ___ of ___ children. How many brothers? ______ How many sisters? ______ 
Describe your relationship with your Siblings ___ Excellent ___ Good ___ Fair ___ Poor ___ N/A 
How would you describe your childhood _________________________________________________ 
Any family history of depression, anxiety, bipolar or other mental health issue? ___ Yes ___ No Explain: 
Educational History 

What was school like for you? ______________________________________________________________ 
Highest level achieved? __________________ What type of grades did you make? ____________________ 
What was your favorite subject? _______________ What was your least favorite subject? __________________ 

Occupation 

Are you currently employed? ___ Yes, full time ___ Yes, part time ___ No 
Employer ________________________________ Occupation ________________________________ 
What do you like/dislike about your employment/career? 
Likes Dislikes 
______________________________________ __________________________________________ 
______________________________________ __________________________________________ 
______________________________________ __________________________________________ 

Would you enjoy doing this job on a long-term basis? ___ Yes ___ No 
Have you ever been fired? ___ Yes ___ No If yes, please explain_____________________________________ 

Legal History 

Have you ever been charged with a crime other than minor traffic violations? ___ Yes ___ No 
If yes, please explain __________________________________________________________________ 
Have you ever been involved in domestic violence? ___ Yes ___ No 
If yes, please explain __________________________________________________________________ 

Health History 

In general, my health is ___ Excellent ___ Good ___ Fair ___ Poor 
Date of your last physical exam? ____________ Are you currently under a doctor’s care? ____ Yes ___ No 
Do you use tobacco? ____ Yes ____ No If yes, how many packs per day?_____ 
The nutritional value and balance of your diet is ___ Excellent ___ Good ___ Fair ___ Poor 
How often do you exercise? ____Daily _____2-4 times per week ____Occasionally _____Rarely 
Has your weight change in recent months? ____ Yes ____ No If yes, how many pounds? _____ 
How much sleep do you get? ____ hours of what quality ___ Good ___ Fair ___ Poor 
Any trouble with sexual functioning? ____ Yes ____ No If yes, explain ___________________________ 
Name of medications you take Dosage/frequency Reason 
____________________________________ _____________________________________ _____________________________________ 
____________________________________ _________________________ _________________________ 
_________________________ _________________________ _________________________ 
_________________________ _________________________ _________________________ 
List any current or previous health concerns (attached additional sheet if necessary): 
________________________________________________________________________________________________________________________________________________________________________________ 
Have you been to a counselor before? ___ Yes ___ No 
If yes, where? __________________________ Dates ___________________ Number of sessions ______ 
Any psychiatric hospitalizations? ___ Yes ___ No 
Previous use of anti-anxiety, anti-depressant, ADHD, or anti-psychotic medication? ___Yes ___ No 
If yes, what and when? _________________________________________________________________ 

Substance Abuse 

Do you use alcohol or drugs? ___ Alcohol ___ Drugs ___ both ___ I don’t use alcohol or drugs 
If you use alcohol or drugs, how often do you use them? 
___ Every day ___ Several times per week ___ Several times per month 
___ Once or twice a month ___ Several times per year ___ Once a year 
Other (explain) ________________________________________________________________________ 
Have you ever felt you should cut down on your alcohol, prescription drugs or other drug use? ___ Yes ___ No 
Has a friend or relative discussed concerns about your use? ___ Yes ___ No 
Have you had to take a drink or use a drug the next day to steady your nerves? ___ Yes ___ No 
Are you a recovering/ recovered alcoholic or drug addict? ___ Yes ___ No 
Is there a history of problems with alcohol or drug use in your family? ___ Yes ___ No 

Religious/Cultural Factors 

Are spiritual or religious issues important to you? ___ Yes ___ No 
What is your religion? _____________________ Name of Church _______________________________ 
How important is your religion to you? ___Not at all ___Slightly important ____Important ___Very important 
Describe how you feel about your spiritual life: 
___ Very happy ___ Happy ___ Ok ___ Unhappy ___ Very Unhappy ___N/A 

Please list any issues that are important or may have affected you in regard to religion or cultural background 
________________________________________________________________________________________ 
________________________________________________________________________________________________________________________________________________________________________________ 

_________________________________________ ____________________ 
Your Signature Date 

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