Relational History Form

Any of the following impacting your relationship(s)?

Are there any health, hormonal, or aging related changes impacting your intimacy with others?

EDUCATION AND LEARNING

I'll be teaching skills, and would like to understand how you prefer to learn new information. Please check all that apply:

I prefer written materials.

I prefer verbal instructions.

I prefer a demonstration before doing.

I need context to understand new information.

EMPLOYMENT

How satisfied are you with your current work/job situation?

Very satisfied

Moderately satisfied

Moderately unhappy

Extremely unhappy

RELATIONSHIP INFORMATION (If Applicable)

Length of time in current relationship

Relationship status: check all that apply

Married

Separated

Divorced

Dating

Living together

Living apart

If yes, who?

My partner

Both

If yes, who?

My partner

Both

Please list any significant relationships have you had before this relationship:

List any children or dependents and their ages:

If yes for either, who, how often and what drugs or alcohol?

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.

I feel emotionally connected to people in general.

I feel emotionally distant from most people.

I can handle stress effectively.

I let stress "spill-over" into my relationships.

I handle issues or disagreements well.

I don't handle disagreements in a mature way, or often feel overly preoccupied, or avoidant of conflict.

I bond well with people I love.

I often feel indifferent about the people in my life.

I often feel guarded, but I desire closeness.

My sex life is fine.

There are problems in this area.

I have a history of cheating.

This is not an issue.

When disagreements arise, I resolve issues well.

Unpleasant fights have occurred frequently for me.

I share my life with people who share my values, goals, and desired lifestyle.

I often share my time with people who do not share my values.

I work well as a team.

I prefer working alone.

10.

I handle my finances well.

I have trouble in this area.

11.

I can have fun with people.

I often feel uptight around people.

12.

I feel worthy of being loved.

I often struggle to feel worthy of a great relationship. Deep down, I worry that if someone knows me, they will not find me worthy of love.

13.

I can easily bond with people, and sustain lasting connections.

I often feel uncomfortable getting too close to people. Or, get bored.

14.

I would describe most of my relationships as superficial or on the surface. It's difficult for me to show my true self. I often mask what I'm truly thinking.

I'm usually at ease and present myself authentically. At least 3-5 people know the real me.

15.

I'm often preoccupied ruminating about my relationships.

I have low anxiety about my relationships.

16.

When in conflict with someone, I'm often confused about what's happening.

When in conflict with someone, I'm not confused.

17.

I practice a lot of "image control" and want to control how others see me.

I don't give much thought to what others think of me.

18.

Demonstrating connection: I remember important details about people, and I'm present for significant/important events.

Demonstrating connection: I struggle to be consistently present. I struggle to remember details about others.

19.

I desire connection with people.

I want to desire connection, but if I'm honest, it isn't a priority.

20.

I'm good at helping others.

If I'm honest, I really only think about helping others if it suits me.

21.

I'm thinking and engaged during conversations.

I'm not fully present during conversations. I feel preoccupied often.

STRESSFUL LIFE EVENTS

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

If yes, please describe

Beyond the information provided here, what else do you feel is important to know about your relationship history?

ACES ASSESSMENT (Early Trauma Assessment)

Please describe any relational traumatic experiences that have impacted your life?

How would you describe your primary maternal figure growing up?

Secure, predictable, calm.

Anxious, too protective of me, intense.

Avoidant, didn't ask personal questions, not close.

Confusing, inconsistent, immature or controlling.

Not applicable.

How would you describe your primary paternal figure growing up?

Secure, predictable, calm.

Anxious, too protective of me, intense.

Avoidant, didn't ask me personal questions, not close.

Confusing, inconsistent, immature or controlling.

Not applicable.

Relational Goals

What do you hope to accomplish through attachment/relational counseling?

I want to get an idea of how you're problem-solving. Please provide at least one suggestion of something you could do to improve your relationships.

Communication Consent

Please call or email if you have questions now.

Lastly, by sending this, I consent to the use of digital forms.

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