Treatment History

Your Name *

Q) Have you sought therapy before or has any prior professional assistance been sought for the problem?

If so, list the name(s), professional title(s), date(s) of treatment:

Name(s):

Professional Title(s):

Date(s) of Treatment:

What was the result of therapy?

Why did the therapy end?

What did you like? What didn't you like?

What worked and what didn't?

Do you have any concerns about abuse of drugs, alcohol, or each other?

Does either partner have health problems?

Is either of you presently taking any medications?

Yes

(If yes, list medications and dosages):

Family member

Medications

Dosages

Has either partner ever attempted suicide?

Yes

Has either partner been hospitalized for psychological problems?

Yes

(If yes, when and where):

Who handles the finances? Is there anything you would change about this area?

Who handles your relationships with your extended families? Is there anything you would change about this area?

How do you make major decisions? Is there anything you would change in this area?

Do you agree about how to discipline your children? What do you do if you disagree? Is there anything you would change about this area?

Q) How do you see your role in this relationship? Is there anything you would change about this area?

Partner A

Partner B

What do you do to spend time together? Is there anything you would change about this area?

How is your sexual relationship? Is there anything you would change about this area?

TREATMENT EXPECTATIONS

Miracle Question (What would be different in your life if you didn't have this problem?):

Partner A

Partner B

What were you hoping to accomplish during counselling? What do you think counselling is all about?

How long do you think it will it take for you to get better?

How will you and I know when we are finished?

Should anyone else be involved?