CLINICAL PSYCHOLOGISTS, P.C.

Background Questionnaire
This questionnaire is to help us get an understanding of your experiences and situations, so that we help
you receive the best possible treatment. Feel free to leave any questions blank which do not apply or
which you prefer not to answer in this format. We will follow-up with you on many of these items.

Your Name: __________________________________ Today’s Date: _________________

Please summarize your reason for seeking services at this time.

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When did you first begin to experience or notice the above concerns you’re seeking help for?
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On a scale of 1-10, where 1 is the least amount of concern/distress you have ever experienced, and 10 is
the absolute highest amount of concern/distress you have ever experienced, what number would you
assign for your level of distress in the last week? ___________

EDUCATIONAL/MILITARY BACKGROUND:

What is the highest school degree you have earned? __________ Are you in school now? _____

During school, did you receive any: ____ Special education? ___ Evaluation for a learning disability?
____ Tutoring? ___ Alternative schooling? ___ Disciplinary actions?

Have you ever served in the military? ____ Yes ____ No

If yes, please answer the following: Date of service: __________________________

Type of discharge: ________________________
Combat experience?_______________________
Highest Rank: ___________________________

WORK/VOCATIONAL HISTORY

What is your current occupation? __________________________________________________

Current Employer: _____________________________________________________________
How long have you been employed in your present position? ____________________________

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 Are you satisfied with your current job? ______Yes ______No
Since becoming an adult, how many different jobs have you held? _____________
Have you had any periods of unemployment, which lasted four months or longer? __Yes __ No
If yes, please describe circumstances briefly: _________________________________________
Have you made any career changes? ______ Yes ______No
If yes, what was/were your previous occupation(s)? ____________________________________
Any major changes in your current work situation during the past year? _____Yes ______No
If yes, please describe: ___________________________________________________________

MEDICAL HISTORY

Please list any medical conditions you have, the type of treatment you are receiving for each, and
your treating physicians.
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Please list all medications you are currently taking, including dosages if you know them:

Medication Dosage Prescribed By

____________________ ______________________ _________________________

____________________ ______________________ _________________________
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Name:_____________________________ Date: _________________

Please list all “over the counter” medications, sleep aids, vitamins, minerals, herbs and/or dietary
supplements you are currently using:

Agent Dosage Condition/Problem

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Have you ever had major surgery? _____ Yes ______ No

Describe:_____________________________________________________________________

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Have you ever had a head injury which resulted in loss
of consciousness or which may have been associated with
a concussion or with problems in thinking, emotion or behavior? _____Yes _____ No

Have you ever had an extremely high fever (greater than 103 degrees F.)? _____ Yes _____ No

Have you ever fainted or had a seizure? _____ Yes _____ No

Do you have any medication allergies or sensitivities? _____ Yes _____ No

If yes, please specify: _______________________________________________________

Do you have any food or seasonal allergies or sensitivities? _____ Yes _____ No
If yes, please specify: _______________________________________________________

Do you regularly engage in physical exercise? _____ Yes _____ No

If yes, please describe: ______________________________________________________

Please list any other medical conditions or concerns:

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Date of last medical examination: ____________________________________________________

Name of Physician: ___________________________________ Contact #: __________________

Would you like me to contact your doctor to coordinate your treatment with him/her: ___Yes ___No

PRIOR EXPERIENCE WITH PSYCHOLOGICAL TREATMENT

Have you been in counseling or psychotherapy previously? _____ Yes _____ No

If yes, please indicate when, and by whom: ____________________________________
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Was your prior counseling/psychotherapy helpful? _____ Yes _____ No

PREVIOUS PSYCHOLOGICAL/PSYCHIATRIC TREATMENT, CONT.

Have you ever taken medications for psychological/psychiatric reasons? _____ Yes ____ No
If yes, please indicate when, and for what conditions/problems:_____________________
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Have you ever been hospitalized for psychological/psychiatric reasons? ____ Yes ____ No

Has anyone in your family (parents, grandparents, siblings, children,

other relatives) been diagnosed and/or treated for psychological/psychiatric
condition(s)? ____ Yes ____ No
If yes, please describe _____________________________________________________
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CURRENT AND PAST USE OF ALCOHOL AND OTHER SUBSTANCES

If you currently drink alcohol, please describe the type of alcoholic beverages, the amounts, and
the frequency: __________________________________________________________________
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If you currently drink alcohol, how many days in the past year have you had 4, 5 or more drinks
in one day? ____________________________________________________________________

If you have used, or currently use, any recreational drugs, please describe which ones and your
pattern(s) of use:________________________________________________________________
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Have you ever tried to cut down on your use of alcohol or drugs? ____ Yes ____ No

Has anyone gotten angry at you because of your alcohol or drug use? ____ Yes ____ No

Have you ever felt guilty or worried about your use of alcohol or drugs? ____ Yes ____ No

Have you ever felt the need for an “eye-opener” in the morning? ____ Yes ____ No

Have you ever received outpatient alcohol and/or drug treatment

or detoxification services? ____ Yes ____ No

Have you ever received inpatient alcohol and/or drug treatment

or detoxification services? ____ Yes ____ No

Has anyone in your family had a problem with alcohol or drugs? ____ Yes ____ No

Please describe your past and current use of cigarettes and/or caffeine: _____________________
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LEGAL ACTIONS/PROCEEDINGS
Please check all legal actions or proceedings you have been a part of:
____ Arrests/Assault ____ Arrests/Other* ____ DUI (how many?___)
____ Restraining/protective order(s) ____ Child Protective Services ____ Divorce/custody
____ Disability claim(s) ____ Other (describe)_______________________________________

PERSONAL INFORMATION

Place of Birth: _________________________ Where were you raised? ____________________

Have you experienced a loss (death, divorce, or significant situational loss)

in the past 24 months? ____ Yes ____ No

Did you experience any losses as above during childhood or adolescence? ____ Yes ____ No
If yes, please indicate whom, and your age at the time of loss:______________________

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Have you relocated or changed jobs within the past 24 months? ____ Yes ____ No

How many siblings do you have, and what is your birth order among them?_________________

Were you adopted or separated from your birth parents during childhood? ____ Yes ____ No

Were/are your parents divorced? ____ Yes ____ No

If yes, please indicate your age at the time of their separation: ______________________

Please indicate your parents’ current ages, or their ages at the time of their deaths:____________

Mother’s occupation(s)/highest level of education:_____________________________________

Father’s occupation(s)/highest level of education:______________________________________

Has religion or spirituality played an important role in your life? ____ Yes ____ No

Has race, ethnicity or culture played an important role in your life? ____ Yes ____ No

Do you own or have access to firearms? ____ Yes ____ No

Have you experienced physical, emotional or sexual trauma or abuse? ____ Yes ____ No
If yes, is this something we can talk about more in person? ____ Yes ____ No

Please check relationship status: _____Married? _____ Separated?

_____Divorced? _____ Widowed?
_____Committed Relationship?
Name of significant other: ________________________ Number of years together?__________

Please describe the quality of your relationship:

___ Excellent ___ Good
___ Needs Improvement ___ Poor
___ Possibly ending relationship
Name:_____________________________ Date: _________________

Do you have children/stepchildren? ____ Yes ____ No

Names & Ages ___________________________________________________________
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What are some of the best (most positive) life experiences you have had?
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What do you consider to be your strengths or talents?

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What are some of the things for which you feel a sense of personal accomplishment/satisfaction?
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How have you gotten through times of hardship or stress in the past?
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What’s going right in your life right now?

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Who, if anyone, can you count on now when you need them? ____________________________

Who, if anyone, really “gets” you and understands how you think or feel or do things?________

What is it like when you are in a satisfying relationship (with peers, colleagues, friends, family
members or loved ones)?_________________________________________________________
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Please use the space below to provide any additional information that you think would be
important for me to know, including your goals for our work together.
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Thank you for taking the time to complete this questionnaire.

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Signature

Reviewed by:_______________________________
Clinical Psychologists, P.C.

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