Julisa Adams, MA
5985 Brandywine Ct
Boulder, CO 80301
(303) 818-6432
www.Julisaadams.com

This is a confidential questionnaire that will provide me with information that will be helpful in your therapy.  If there are questions that you would rather not answer, leave them blank.  Use the back of these pages, or attach extra pages if necessary.  Please mail or e-mail it to me before we meet, so I will be well prepared for the first session.

Name: ________________________________________________________

Address: ______________________________________________________

Phone: (home)____________  (cell)____________  (work)____________

Can I leave a message at any of the above? ________________________

e-mail: ________________________________________________

How did you hear of me? ____________________ Birth date: _______________

Emergency contact: _____________________________ Phone: ____________

1.	What brings you in to therapy at this time?

2.	How will you know therapy has helped you? How will you and your life be different? What are your therapy goals?

3.	Names, ages and a brief description of the people you live with.

4.	Education (list degrees and courses of study).

5.	Basic work history, degree of satisfaction with jobs.

6.	Health history (significant past and present health concerns, current medications, including supplements). Have you ever been given a psychiatric diagnosis? Medication for that?

7.	Do you have problems with:
_______Alcohol			______insomnia
_______drugs or cigarettes	______PMS
_______sexual issues		______anger
_______depression			______moods
_______body image		         ______anxiety

8.	Family of Origin
A.	What kind of relationship did/do you have with:

Your Mother:

Your Father:

Your Siblings:

Other significant people:

B.	What was the mood of the house as you were growing up?

C.	Have you even been sexually or physically abused? Tell me a little about it, if so.

D.	List the main traumas in your life and the age they occurred at.

9.	Relationship History (choose the most important relationships) Names, dates, brief descriptions of partners and basic qualities of the relationship.

10.	What are your intimacy issues, patterns and trends?

11.	Describe yourself, including positive and negative traits.

12.	Have you ever made a suicide attempt? _____  Please give details:

13.	What do you need and want from me? What do you know works or doesn’t work for you?

14.	What has been your experience with therapy before? What helped, or didn’t help?

15.	Anything else you want me to know?

16.	Let’s look at your diet and life-style…

a.	How often and what kind of sugar do you eat?

b.	How often and what kind of protein do you eat?

c.	Tell me about your food habits in general, such as a typical day’s food and foods you eat a lot of (i.e. ice cream every night, soda in the afternoon, alcohol, etc.)

d.	What are your issues and feelings about food?

e.	 What do you do for exercise?

17.What makes you happy or helps you feel spiritually connected?

18.  Therapy is a powerful and life changing process.  It requires consistent commitment, particularly when things get uncomfortable or challenging.   It is a complex and personal relationship between therapist and client, which requires mutual respect, honesty and good communication.  Cancellations undermine the work and diminish effectiveness.  We will be working with your mind, body, nervous system, unconscious mind and your deepest self.  To create stability and effectiveness it is essential for you to maintain a commitment to weekly sessions, or, at a minimum, every other week.  When you want to end therapy, it is very important to discuss that with me and to do it in a conscious and respectful fashion.  Do you have any questions or concerns about agreeing to this foundation for beginning to work together?