Marianne O'Byrne, M.A., Ph.D. (Candidate)
Clinical Therapist
LIFE HISTORY QUESTIONNAIRE
The purpose of this questionnaire is to obtain a comprehensive understanding of your life experience and background. Completing these questions as fully and as accurately as you can will benefit you through the development of a treatment program suited to your specific needs.
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Marianne O'Byrne, M.A., Ph.D. (Candidate)
Clinical Therapist
Date
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Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
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Aruba
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Burkina Faso
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Colombia
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Democratic Republic of the Congo
Denmark
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Ethiopia
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France
French Polynesia
Gabon
The Gambia
Georgia
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Ghana
Gibraltar
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Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
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Oman
Pakistan
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Paraguay
Peru
Philippines
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Poland
Portugal
Puerto Rico
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Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
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Saint Lucia
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Samoa
San Marino
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Senegal
Serbia
Seychelles
Sierra Leone
Singapore
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Somaliland
South Africa
South Ossetia
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Spain
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Sudan
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
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Ukraine
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United States
Uruguay
Uzbekistan
Vanuatu
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Isle of Man
US Virgin Islands
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Other
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Cell Number
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Area Code
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Messages Allowed
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Home Number
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Area Code
Phone Number
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Date of Birth
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Age
Occupation
By whom were you referred
With whom are you now living? (List people):
Significant relationship status (check one):
Single
Engaged
Married
Separated
Divorced
Remarried
Committed Relationship
Widowed
If married, partner’s name, age, occupation?
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Marianne O'Byrne, M.A., Ph.D. (Candidate)
Clinical Therapist
1. ROLE OR RELIGION AND/OR SPIRITUALITY IN YOUR LIFE:
A. In Childhood
B. As an adult
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Marianne O'Byrne, M.A., Ph.D. (Candidate)
Clinical Therapist
2. CLINICAL
A. State in your own words the nature of your main problems and how long they have been present:
B. Give a brief history and development of your complaints (from onset to present):
C. On the scale below, please check the severity of your problem(s):
Mildly upsetting
Moderately severe
Very severe
Extremely severe
Totally incapacitating
D. Whom have you previously consulted about your present problem(s)?
E. Are you taking any medication? If “yes”, what, how much, and with what results?
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Marianne O'Byrne, M.A., Ph.D. (Candidate)
Clinical Therapist
3. PERSONAL DATA
A. Place of birth:
B. Mother’s condition during pregnancy (as far as you know
C. Check any of the following that applied during childhood:
Night Terrors
Bedwertting
Sleepwalking
Thumb Sucking
Nail biting
Stammering
Fears
Happy childhood
Unhappy childhood
D. Health during childhood? List illnesses
E. Health during adolescence? List illnesses
F. What is your height?
Your weight
G. Any surgical operations? (Please list them and give age at the time)
H. Any accidents:
I. List your five main fears:
J. Select any of the following that apply to you
Headaches
Dizziness
Fainting spells
Palpitations
Stomach trouble
Anxiety
Bowel disturbances
Fatigue
Insomnia
Nighmares
Feel panicky
Alcoholism
Feel tense
Conflict
Tremors
Depressed
Suicidal ideas
Take drugs
Unable to relax
Sexual problems
Allergies
Overambitious
Shy to people
Can't make friends
Inferiority feelings
Can't make decisions
Can't keep a job
Memory problems
Home condition bad
Financial problems
Lonely
Unable to have a good time
Excessive sweating
Often use aspirin or painkillers
Concentration difficulties
Don't like weekends and vacations
Please list additional problems or difficulties here.
K. Select any of the following words which apply to you:
Worthless
Useless
A "nobody"
"Life is empty:
Inadequate
Stupid
Incompetent
Naive
"Can't do anything right"
Guilty
Evil
Morally wrong
Horrible thoughts
Hostile
Full of hate
Anxious
Agitated
Cowardly
Unassertive
Panicky
Agressive
Ugly
Deformed
Unattractive
Repulsive
Depressed
Lonely
Unloved
Misunderstood
Bored
Restless
Confused
Unconfident
In conflict
Full of regrets
Worthwhile
Sympathetic
Intelligent
Attractive
Confident
Considerate
Please list any additional words:
L. Present interests, hobbies, and activities:
M. How is most of your free time occupied?
N. What is your last grade of school that you completed?
O. Scholastic abilities, strengths and weaknesses:
P. Where you ever bullied or severely teased?
Q. Do you make friends easily? Do you keep them?
Marianne O'Byrne, M.A., Ph.D. (Candidate)
Clinical Therapist
Marianne O'Byrne, M.A., Ph.D. (Candidate)
Clinical Therapist
Marianne O'Byrne, M.A., Ph.D. (Candidate)
Clinical Therapist
Marianne O'Byrne, M.A., Ph.D. (Candidate)
Clinical Therapist
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