Life History Questionnaire Please enable JavaScript in your browser to complete this form.The purpose of this questionnaire is to obtain a comprehensive understanding of your life. By completing this questionnaire, as fully and accurately as you can on your own time, you will provide me with important information without using actual therapy time. It helps me customize your sessions and design tools that address your needs. The information you share is confidential. If you do not wish to answer a question, just simply write “SKIP.” *I AcknowledgeName *FirstLastAgeOccupationHow did you find Sensorium Hypnosis?List of members in your household (name, age, relationship to you):Marital Status SingleEngagedMarriedSeparatedWidowedNumber of MarriagesIf applicable, please provide main reasons for separation/divorceClinicalState in your own words the nature of your main challenge(s) and how long you have been strugglingGive a brief account of the history and development of your challenges (onset to present)From the choices below, please choose the word/phrase that best represents the severity of your challenge(s)Choose OneMildModerateSevereExtremely SevereTotally IncapacitatingWith whom have you previously consulted about your presenting issue? How long did you receive services? OCCUPATIONALWhat sort of work are you doing and for how long?About how many hours do you work per day/per week? Do you have a set start and end time?What type of work have you done in the past?Does your present work satisfy you? Why or why not? Are there any parts of your job that create too much stress and if so, please describe? Ambitions regarding work/career?OTHER AREASInterests, hobbies & leisure activitiesHow is most of your free time occupied presently?Last grade of school completed?Other certifications, licenses, credentials? Scholastic abilities; strengths/weaknessesWere you ever bullied or teased at school when you were a child/teenager? If so, how did this impact you?Do you make friends easily and if so, do you keep them?Characteristics of your closest friends?List (5) of your biggest fears/concerns: ATTITUDESCheck any of the following thoughts that may enter your head from time to timeI am worthlesslife feels emptyI have nothing to look forward toI feel inadequateI feel guiltyI am deeply misunderstood by othersI have so many regretsI am not attractiveI wish I were smarterI don’t have any real friendsI feel panicky and anxious a lotI feel unlovedEverything I do turns into disasterI get burned too easilyPeople take advantage of meI make poor decisions and can’t even trust my own judgmentI seem to attract chaosWhy are so many psychologically unhealthy people attracted to me?If I had a better upbringing, I would not struggle like thisNo matter what I do, I never seem to get aheadAny additional attitudes not listed aboveCheck any of the following issues that apply to you HeadachesFinancial problemsLack of appetiteOvereatingIntestinal disturbancesInsomniaNightmaresFatigueAlcoholismDrug abuse (prescription/street)Anxiety/PanicDepressionTense in social situationsDifficulty making decisionsTrouble making/keeping friendsDifficulty holding down a job long-termUnable to relax and have a good timeDifficulty focusing/concentrating/rememberingDifficulty making long-term commitments/following throughFAMILY DATAHow well do you get along with your family of origin? (please explain)How well do you get along w/ your partner’s family, if applicable? (please explain)If you or your partner are divorced, please describe to what extent the relationships with ex’s affect your life/livesPlease list any children living at home, as well as any of your partner’s children living with you full or part-time, if applicable, along w/ their ages and a few of their dominant personality traits:Do you have any relationship challenges with any of your children? If so, please describe nature of issue(s)Regarding your father, is he living/deceased?YesNoIf deceased, age and cause of death?If alive, father’s present age?Health issues?To what extent are you responsible for his care, if applicable?Regarding your mother, is she living/deceased?YesNoIf deceased, age and cause of death? If alive, mother’s present age?Health issues? To what extent are you responsible for her care, if applicable?Please provide a short description of your upbringing, home environment, parents’ style of discipline, emotional availability of parents (could you talk about personal things?), your parents relationship with each other, your relationship with siblings, if applicableIf you had a stepparent(s), brief description of relationship. What point did they come into your life? Were you raised in any formal religion? If so, which religion? And were you affiliated with a specific church and how long did you attend? If you left the church, why? What are your beliefs in terms of religion or spirituality now? (higher power, angels, spirit guides, afterlife, etc.)Who are the most important people in your life now – those who are most supportive to you? SELF DESCRIPTIONI AM:I AM:I AM:I AM: I FEEL:I FEEL: I FEEL: I FEEL: I THINK:I THINK:I THINK: I THINK: I WISH:I WISH: I WISH: I WISH: Please check the areas hypnosis could helpImprove my relationship with parents/kids/spouse/boss/co-worker/friendsgain better self-controlhave more positive inner dialoguehelp with self-esteemmanage stress bettertake better care of myselfsetting boundaries with othersfinding healthier work/life balanceovercome fearsself-discovery and finding my own truth/pathclarity about career/marriage/faith-spirituality-religionSubmit
