PERSONAL HISTORY/PROBLEM EVALUATION

BASIC INFORMATION ABOUT THE PROBLEM

Personal Information








THE BASIC PROBLEM AS YOU UNDERSTAND IT (Briefly complete the following):

DETAILED INFORMATION RELATED TO THE PROBLEM

Information about spiritual life:




(ONLY IF APPLICABLE) SPOUSE'S CHURCH ATTENDANCE:




























INFORMATION ABOUT PRIOR COUNSELING




INFORMATION ABOUT PERSONAL HABITS AND HEALTH

WHEN DO YOU NORMALLY:
















MARRIAGE AND FAMILY INFORMATION: