Fillable Printable Biodata Form for Consultant

Biodata Form for Consultant

BIOGRAPHICAL INFORMATION

Please fill out this biographical background sheet as completely as possible. It will help me in

our work together. All information is confidential as stated in the Counseling Agreement Form.

If you do not desire to answer a particular question, please indicate it on the form. Please bring

this package, signed and filled out, to your next session.

Name: _________________________________________ male/female __________

Address: _____________________________________________________________

Phone: h ___________________ w ___________________ c __________________

DOB: ______________ Place of Birth: ___________________________________

Person & phone# to call in emergency: ____________________________________

______________________________________________________________________

Occupation/Employer: __________________________________________________

Relationship Status/Living Arrangement: __________________________________

Significant Past Relationships:_____________________________________________

_______________________________________________________________________

Children (incl. Step- or grand-): ____________________________________________

_____________________________________________________________

Referral Source: ________________________________________________________

Presenting Problem(s) (be as specific as possible: time it started; how it affects you or others

around you; etc.): ___________________________________________________

_____________________________________________________________

Estimated Severity of ….

Problem 1: mild _____ moderate _____ severe ____

Problem 2: _____ _____ _____

Problem 3: _____ _____ _____

Medical Doctor(s) (name & phone#):_________________________________________

_____________________________________________________________

Past/Present Medical Care (major medical problems, surgeries, accidents, falls,

illness):_________________________________________________________________

______________________________________________________________________________

__________________________________________________________________

Specify all MEDICATIONS you are presently taking and for what. PLEASE PRINT

clearly:__________________________________________________________

__________________________________________________________________

________________________________________________________

_____________________________________________________________

Family History (give name/age or date of death, occupation, and a brief description of the

nature of your relationship when you were a child and as an adult):

Mother:____________________________________________________________

__________________________________________________________________

______________________________________________

Father:_____________________________________________________________

__________________________________________________________________

______________________________________________

Other Caregivers:________________________________________________________

__________________________________________________________________

___________________________________________________

Siblings:____________________________________________________________

__________________________________________________________________

______________________________________________

Family Medical History (Describe any illness that runs in the family: cancer, epilepsy,

etc):___________________________________________________________________

_____________________________________________________________________________________

Drug/Alcohol/Other Addiction History:

Parents/

Caregivers:__________________________________________________________

__________________________________________________________________

_____________________________________________

_____________________________________________________________

Self (If no personal history with drugs or alcohol, what is your current consumption):

__________________________________________________________________

___________________________________________________

Suicide Attempts or Self-Harming Behaviors (describe ages, reasons, circumstances, how,

etc):________________________________________________________________

______________________________________________________________________________________

_____________________________________________________________

Friendships, Community, & Spirituality (describe the quality, frequency, type of activities,

etc.):___________________________________________________________

______________________________________________________________________________________

Past/Present Psychotherapies (give time frames, name, degree, phone & address, initial reason

for therapy, medication, brief description of the relationship and how helpful it was, and how/

why it ended):

1. ____________________________________________________________________________________

______________________________________________________________________________________

2. ____________________________________________________________________________________

______________________________________________________________________________________

What gives you most joy or pleasure in your life: ____________________________________

_____________________________________________________________________________________________

_______________________________________________________________________________

What are your main worries and fears:_________________________________

_____________________________________________________________________________________________

_______________________________________________________________________________

What are your most important hopes or dreams: ___________________________________

_____________________________________________________________________________________________

_______________________________________________________________________________