Life History Questionnaire - Adult
The purpose of this questionnaire is to obtain a comprehensive understanding of your life experiences and background. Please complete these questions as fully and as accurately as you can. It will help to development of a treatment program suited to your specific needs.
Today's Date *
MM
/
DD
/
YYYY
Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Phone # *
Your answer
Type *
OK to leave voicemail on this # *
Phone # Secondary
Your answer
Type (secondary #)
OK to leave voicemail on secondary #
Date of Birth *
MM
/
DD
/
YYYY
Age *
Your answer
Occupation
Your answer
In case of emergency contact *
Your answer
Contact Phone *
Your answer
Who referred you
Your answer
With whom are you now living? (List people and relationships) *
Your answer
Where do you reside
Significant relationship status *
If married, spouses name, age & occupation
Your answer
I identify as: (check all that apply)
Please describe other if you checked this box
Your answer
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