Family History Survey
You are about to begin an assessment that will provide Currents Counseling with information related to your family history. All answers are required unless specified as optional.
Be open and honest with your answers. This is a confidential survey. All information provided will be used strictly as a part of your therapy. Thank you.
What is your name (first and last)?
How old are you? (enter number)
Were your parents ever separated or divorced while you lived at home?
If both parents are living, are they still together?
N/A: At least one parent is no longer living.
Which best describes your upbringing through MOST of your childhood?
Lived with 2 parents, both biological.
Lived with 2 parents, one biological
Lived with 2 parents, adopted
Lived with 1 parent, biological
Lived with 1 parent, adopted
Lived with other family members
Lived in foster homes
How many other siblings did you live with before you were 18 years old? How much older/younger were they?
Were there any deaths in you immediate family while you lived at home? If so, please explain.
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