Michael D. Penticuff, Ph.D.
Licensed Psychologist
Voice: (512) 454-9300 FAX: (512) 454-9370
1300 West Lynn Street, Suite 110
Austin, Texas 78703
Information About Your Life
CURRENT LIVING ARRANGEMENT
Please circle your living arrangement: house, room, apartment, other
With whom are you now living, and how are you related to them?Are there any problems with your current living arrangement (describe)?
RELATIONSHIP HISTORY (Please answer these questions with respect to current and past marriages/significant relationships)
What is your current (romantic) relationship status? For how long?How long did you know your partner/ex-partner before making the commitment?
What is/was your partner's date of birth? __________ Occupation? ____________
In what ways are/were you compatible?
In what ways are/were you incompatible?
How satisfactory is/was your relationship(s)?
How do/did you get along with your partner's relatives?
How does/did your partner(s) get along with your relatives?
Do you have children? __________ or do you plan to have children?__________
How many children do you have, or plan to have?
Were your current children planned?
Please describe any children involved in your relationship:
How do you feel about your skills as a parent, and about your partner's skills in that area?
Who are the most important people in your life?
Do you make friends easily?
Do you keep friends once you have made them?
With whom are you likely to share your deepest feelings?
VOCATIONAL AND EDUCATIONAL MATTERS
What is your educational background?
Do you feel that your education is satisfactory?
What is your current employment status? In what kind of setting?
What other important employment history do you have?
What is your view of yourself as a member of the workforce?
Does your work life contribute to your sense of well-being, or is it a source of stress for you?
FAMILY OF ORIGIN
Where were you born?Were there any problems surrounding your mother's pregnancy with you or her delivery of you? If so, please elaborate.
Please describe your father in terms of his age, psychological or physical strengths and problems, his attitude toward you when you were a child and later, and his attitude toward your mother and any siblings. If he is dead, please indicate his age and your age at the time of his death.
Please describe your mother in terms of her age, psychological or physical strengths and problems, her attitude toward you when you were a child and later, and her attitude toward your father and any siblings. If she is dead, please indicate her age and your age at the time of her death.
Please also describe the course of your parents' relationship. That is, were they married at the time of your birth, did their marriage last until one of them died, did they divorce, are they still married, etc.?
If you had one or more step-parents, please discuss them in terms similar to those suggested above for your parents.
What was it like to grow up in your home?
If you have (or had) any siblings, please discuss them in terms of where you fell in the birth order and any significant ways in which your relationships with them affected you as you became who you are.
What are the drinking and substance use habits in your family of origin?
Were you able to confide in your parents?
What forms of reward and punishment do you recall from your childhood?
PHYSICAL HEALTH
How would you describe your physical health?
Please list any physical limitations.
Please list any health problems.
Daily consumption of caffeine products: ____________________________________
Tobacco products: _____________________________________________________
Alcohol: ____________________________________________________________
Are you using any prescription medications? If so, which ones?
Any non-prescription medications?
Other drugs?
Do you ever binge-eat?
Do you ever purge?
Please describe your typical sleep habits and patterns.
When were you last examined by a physician?
In what forms of physical exercise do you regularly engage?
(Women) Age at first period: __________ Prepared or a shock? __________Any menstrual problems? __________Do your periods affect your moods or cause any physical changes or other problems? (If yes, please elaborate)
Number of pregnancies: __________ Miscarriages: __________ Abortions: __________ Contraception used: __________
SEXUALITY
What were your parents' attitudes toward sex?
At what age and how did you derive your first knowledge of sex?
Are you satisfied with your sexuality and with your sexual relationships?
Do you have any sexual problems now? If so, please elaborate.
LIFE EXPERIENCES
What people, events, habits, books, or other influences have been most helpful to you in your life?
What are some of the best times you can recall?
What are some of the most difficult times you have faced?
What makes you feel most anxious or frightened now?
What most helps you to feel calm, relaxed and secure?
What directions have you set for yourself in life?
What do you do with leisure time?
What roles have spirituality and religion played in your life?
PAST COUNSELING OR THERAPY
Please describe any experiences with counseling, psychotherapy, hospitalizations for psychological problems, etc. When have these experiences occurred, and how long did they last?
What were you working on?
Do you feel you benefited from this experience? If not, why not?
Why did it end?
Have you ever thought about hurting yourself or made a suicide attempt? If so, please describe.
CURRENT SITUATION
Why are you seeking psychological services at this time?
How long have you felt this need?
Have you sought professional help for this before? If so, what happened?
What about your safety? Are you in a safe situation (or are you in an abusive relationship or a suicidal frame of mind)?
What do you hope to gain from working with a psychologist?
Name ________________________________________
Address ________________________________________
Telephone Number ____________________
Date of Birth ____________________Return to Top
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