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Life History Questionnaire

A detailed questionnaire clients fill in before starting therapy, covering family, relationship, school, work and personal history. It helps psychologists and therapists understand the background and severity of the presenting concerns.

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All of your answers are confidential

Full Name*

First Name

Last Name

Date*

Date of Birth

Marital Status

Single Married Domestic partnership Separated Divorced Widowed

If married, how many times?

Details of any previous marriages

Who currently lives with you?

How many children do you have? List each one's sex and age

Do any of your children have special difficulties?

Who are the most important people in your life?

Is your father living or deceased?

Living Deceased Unknown

If deceased, how old were you at the time?

What was the cause of his death?

If living, his current age, occupation and health

Is your mother living or deceased?

Living Deceased Unknown

If deceased, how old were you at the time?

What was the cause of her death?

If living, her current age, occupation and health

How do you get along with your in-laws?

In which areas of family life is there compatibility?

In which areas is there incompatibility?

Describe the atmosphere of your childhood home

As a child, how did your parents discipline you?

If your parents did not raise you, who did, and from what age?

Could you confide in your parents or caregivers?

If you have a stepparent, how old were you when your parent remarried?

Describe your religious affiliation and experiences

Has anyone ever interfered in your marriage?

What were your parents' attitudes toward sex?

When, and at what age, did you first learn about sex?

When did you first become aware of your own sexual urges?

Have you ever felt anxiety or guilt related to sex?

What are your current interests, hobbies and activities?

How do you spend most of your free time?

What is the last school grade you completed?

What were your academic strengths and weaknesses?

Were you ever bullied or teased?

Do you make friends easily, and do you keep them?

What work do you do now?

What work have you done in the past?

Are you satisfied with your current work? If not, why?

Describe your past career ambitions

Describe your current career ambitions

Has anyone ever interfered with your work life?

List your five main fears

Briefly describe how your difficulties began and developed up to now

Estimate how severe your problems are

Mildly upsetting Moderately severe Very severe Extremely severe Totally incapacitating

Whom have you consulted before about these problems?

Is there anything else you would like to add?

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