CONFIDENTIAL PROFILE

Please answer all questions as completely as you are willing. Do not hesitate to ask any questions.

Page 2 of 7

THe following PAGEs SHOULD BE FILLED OUT AND ONLY SEEN BY THE CLIENT.

Name

First Name

Last Name

Please describe the person or people with whom you live.

If solo, describe you as a "roommate" to you.

Tell me anything you want to share about your parents.

We're you adopted?

If you were adopted, do you know your birth mother or father or both?

How many members are in your immediate family?

Type "N/A" if there are none.

Tell me about your brothers and sisters.

Type "N/A" if there are none.

Tell me about your children.

Type "N/A" if there are none.

Have you ever been hospitalized for medical or emotional reasons?

If "yes" to the preceding question, what is important to know about the experience?

Have you ever been in an accident or other traumatic experience (e.g., natural disaster, war, violent crime, etc.)?

If "yes" to the previous question, please explain.

Have you or any of your family members ever been arrested or convicted of a felony?

Talking about Immediate family or close family members such as a cousin.

If "Yes" to the previous question, please explain in detail.