The purpose of this questionnaire is to get a complete picture of your couple, marital, and family background. In marriage and family therapy we are concerned with issues that impact on you, your marriage, and your family from many sources. Among those sources are (a) your family orgin, that is your parents and grandparents, (b) your physical health, (c) your life history, and (d) things that are influencing you right now. By asking you about these things in questionnaire form we can save a great deal of valuable therapy interview time. Therefore, answering these routine questions as fully and as accurately as you can will make it possible for us to get to work on the things that concern you much more quickly.
All case records are confidential. Except where legally mandated, these records will be seen by no one without your written permission.
If you have any questions about this questionnaire, please feel free to ask at any time. If you do not wish to answer a question, ) You may write "I do not wish to answer.