Relational History Form

Please correct the errors described below.

Any of the following impacting your relationship(s)?

EDUCATION AND LEARNING

EMPLOYMENT

RELATIONSHIP INFORMATION (If Applicable)

Self-Awareness Questions

For each of the statements below, check the box that best describes how you feel now - don't give it much thought. Go with your first "gut" response.

STRESSFUL LIFE EVENTS

Please describe any significant or stressful life events you have been experiencing:

ACES ASSESSMENT (Early Trauma Assessment)

Relational Goals

Communication Consent

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