Pre-Marriage Intake

PRE-MARITAL PERSONAL AND SOCIAL HISTORY

EPISCOPAL COUNSELING CENTER CLIENT'S NAME:________________________

FAMILY OF ORIGIN

A. FAMILY OF HOME:

I was born in _______________________________________ and reared in _____________________________________

When I was a child, the condition where I lived were:

⁬ happy ⁬ peaceful ⁬ protective ⁬ warm ⁬ $ well off

⁬ sad ⁬ tense ⁬ violent ⁬ cold ⁬ $ poor

Discipline at home was: ⁬ strict ⁬ moderate ⁬ permissive ⁬ inconsistent ⁬ harsh

B. FAMILY RELATIONSHIPS
⁬ I am an only child
⁬ I am the ____ of ____ children.
⁬ I am a ___ twin/ ___ triplet
⁬ I am adopted and I ___ do / ___ do not know my natural parents
⁬ My parents divorced when I was ____ years old
⁬ I was reared by someone other than my parents. (Who?) ______________________________
⁬ I have a step-parent(s)
⁬ I have ____ brothers and ____ sisters
⁬ I have ____ half-sisters and/ or ____ half-brothers
⁬ I have ____ step-sisters and/ or ____ step-brothers

FATHER: Name: _______________________________________________ Age ________

Occupation: ___________________________________________ Health _______

If deceased, give his age at time of death: ________ How old were you? _________

Cause of Death: _____________________________________________________

MOTHER: Name: _______________________________________________ Age ________

Occupation: ___________________________________________ Health _______

If deceased, give her age at time of death: ________ How old were you? _________

Cause of Death: _____________________________________________________

SIBLINGS: Age(s) of brother(s): ______________________ Age(s) of sister(s) __________________

Any significant details about siblings: _____________________________________________________________________

__________________________________________________________________________________________________

Does any member of your family suffer from an "emotional" or "mental" disorder? _____ Yes _____ No

Have any relative attempted or committed suicide? _____ Yes _____ No

Give a description of your father's (or substitute's) personality and his attitude toward you ( past and present): Use back if necessary

__________________________________________________________________________________________________

Give a description of your mother's (or substitute's) personality and his attitude toward you ( past and present): Use back if necessary

__________________________________________________________________________________________________

Growing up I felt closest to _________________________ Because ____________________________________________

I felt least close to ________________________________ Because ____________________________________________

Give an impression of your home atmosphere (i.e., the home in which you grew up). Mention state of compatibility between parents and between children

__________________________________________________________________________________________________

Were you able to confide in your parents? ⁫ Yes ⁪ No If no, then in whom? _____________________________________

Basically, did you feel loved and respected by your parents? ⁫ Yes ⁪ No

If you have a step-parent, give your age when your parent remarried: Father __________ Mother _________

Has anyone (parents, relatives, friends) ever interfered in your marriage, occupation, ect? ⁫ Yes ⁪ No

If Yes please describe breifly: _________________________________________________________________________

________________________________________________________________________________________________

⁫ Happy Childhood	⁫ Not Enough Friends	⁫ Sexually Abused
⁫ Unhappy Childhood	⁫ School Problems	⁫ Severely Bullied or Teased
⁫ Emotional/ Behavior problems	⁫ Financial Problems	⁫ Eating Disorder
⁫ Legal Trouble	⁫ Strong Religious Convictions	⁫ Others: ____________________
⁫ Death in Family	⁫ Drug Use	________________________
⁫ Medical Problems	⁫ Used Alcohol	________________________
⁫ Ignored	⁫ Severely Punished	________________________

What kind of hobbies or leisure activities do you enjoy or find relaxing? ___________________________________

________________________________________________________________________________________________

Do you have trouble relaxing or enjoying weekends or vacations? ⁫ Yes ⁪ No If YES, please explain:

________________________________________________________________________________________________

List your five main fears:

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Describe any situations that make you feel calm or relaxed:

________________________________________________________________________________________________

Check any of the following that apply

	Never	Rarely	Occasionally	Frequently	Daily
Diet Pills
Marijuana
Sleeping Pills
Aspirin
Cocaine
Narcotics
Hallucinogens (e.g. LSD)
Laxatives
Cigarettes
Tobacco (Cigars/Chewing)
Coffee
Alcohol
Others:

Using the scale below, please rate each statement:
(Strongly Disagree = 1; Disagree = 2; Neutral = 3; Agree = 4; Strongly Agree = 5

_____ I should not make mistakes.
_____ I should be good at everything I do.
_____ When I do not know something, I should pretend that I do.
_____ I should not disclose personal information.
_____ I am a victim of circumstances.
_____ My life is controlled by outside forces.
_____ Other people are happier than I am.
_____ It is very important to please other people.
_____ Play it safe; don't take risks.
_____ I don't deserve to be happy.
_____ If I ignore my problems, they will disappear.
_____ It is my responsibility to make other people happy.
_____ I should strive for perfection.
_____ Basically, there are two ways of doing things -- the right way and the wrong way.
_____ I should never be upset.