Dr. Beth Sherman - Questionnaire

Full Name *

Date *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Email Address *

Home Phone *

Cell Phone *

Is it ok to leave messages at all of these numbers?

YesNoSelect Answer

Social Security Number:

Date of Birth *

Please give details of any previous marriage(s):

With whom are you now living? (List people, their ages, and your relationship with them)

CLINICAL DATA

Tell me about yourself

Reason for Interest

Previous Therapy

Have you ever been hospitalized for psychological/psychiatric problems?

YesNo

If yes, when and where?

Date

Have you ever attempted suicide?

YesNo

On the scale below, please estimate the severity of your problem(s).

Mildly upsettingModerately upsettingVery upsettingExtremely severeTotally incapacitating

Who is most affected by your problem(s) and why?

When are your problem(s) less severe?

When are your problem(s) more severe?

What have you tried in an attempt to alleviate your problem(s)?

How does your problem(s) interfere with work/school, social life, close relationships?

Why do you think you have your problem(s)?

How will we know when we’re finished with therapy?

What would be different if your presenting problem(s) didn’t exist?

How long do you think your therapy should last and why?

Family and Childhood Data

If Other

Describe a very pleasant image, mental picture, or fantasy:

Describe a very unpleasant image, mental picture, or fantasy:

Describe your image of a completely “safe place”:

Describe any persistent or disturbing images that interfere with your daily functioning:

How often do you have nightmares?

Friendships

Do you make friends easily?YesNo

Do you keep them?YesNo

Did you date much during high school?YesNo

College?YesNo

Were you ever bullied or severely teased?YesNo

Please describe any relationship that gives you joy:

Please describe any relationship that gives you grief:

Rate the degree to which you generally feel relaxed and comfortable in social situations:

Do you have one or more friends with whom you feel comfortable sharing your most private thoughts?

Marriage/Committed Relationship

(please skip to the next section if not applicable)

How long have you been married?

How long did you know your marriage partner before engagement/marriage?

Spouse’s age?

Spouse’s occupation?

Describe your spouse’s personality:

In what areas is there compatibility?

In what areas is there incompatibility?

What factors detract from your marital satisfaction?

On the scale below, please indicate how satisfied you are with your marriage:

How do you get along with your partner’s friends and family?

Children

(please skip to the next section if not applicable)

How many children do you have ?

List their first names, gender, and ages:

Do any of your children present special problems?

Personality of each child:

Sexual Relationships

Describe your parents’ attitudes towards sex ?(i.e., was there sex instruction or discussion in the home?)

When and how did you acquire your first knowledge of sex?

Did you ever experience anxieties or guilt feelings arising out of sex or sexual activities?YesNo

If yes, please explain:

If yes, please explainAre there any relevant details regarding your first or subsequent sexual experiences?

Is your present sex life satisfactory?YesNo

If yes, please explain:

Other Relationships

Are there are problems in your relationships with people at work?YesNo

If yes, please explain:

Please complete the following:

One of the ways people hurt me is:

I could shock you by:

My spouse/partner/boyfriend/girlfriend would describe me as:

My best friend thinks I am:

People who dislike me:

Are you currently troubled by any past rejections or loss of a love relationship?YesNo

If yes, please explain:

Family and Childhood

Father

Living or Deceased?LivingDeceased

Cause of Death?

If alive, father’s present age?

Occupation (if retired, what was the occupation)?

Mother

Living or Deceased?LivingDeceased

Cause of Death?

If alive, mother’s present age?

Occupation (if retired, what was the occupation)?

Occupational Data

What sort of work are you doing now?

Types of jobs in the past?

Does your present work satisfy you? If not, in what ways are you dissatisfied?

Ambitions: past and present?

Situational Data

Recount any fearful or distressing experiences not previously mentioned:

List any situations that make you feel particularly anxious:

List the benefits you hope to derive from counseling:

List any situations that make you feel particularly anxious:

List any situations that make you feel calm or relaxed:

Have you ever lost control, i.e., temper, crying, aggression?

ADDITIONAL INFORMATION

Have you ever used drugs?

Have you ever had any medical consequences of alcohol/drug usage (blackouts, seizures, shakes, hallucinations, etc…

Any legal problems related to alcohol/drug use?

Describe your pattern of alcohol usage:

Please describe any significant childhood (or other) memories and experiences you think may be relevant:

Questionnaire

Or Fill out digitally / Form will be emailed to secure email.

Have you ever been hospitalized for psychological/psychiatric problems?

Have you ever attempted suicide?

On the scale below, please estimate the severity of your problem(s).

Family and Childhood Data

Check any of the following conditions that often apply to you: (please indicate if it’s only during high anxiety)

I have:

Give an outline of your religious training:

Select any of the following that applied during your childhood:

Specialty Areas

Recent Articles

Pages

Specialties

CONTACT

Questionnaire

Or Fill out digitally / Form will be emailed to secure email.

Is it ok to leave messages at all of these numbers?

Marital Status

Specialty Areas

Recent Articles

Pages

Specialties

CONTACT