Associates for Counseling Services, P

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					                          Associates for Counseling Services, P.A.
                             Childhood and Marital History Form

                          Chart #:

      Name:


                                           Full Name                             Current Age
    Mother
     Father
  List Siblings




              If any family member has a history of psychiatric or substance abuse
                         problems, please explain in the text box below.




                                       Marital History

                         First Marriage                         Current residence or comments.
Name of spouse
Date started
Date ended
Reason

                                                   Current
                                                    Age
Name of child 1
Name of child 2
                            Second Marriage                         Current residence or comments.
Name of spouse
Date started
Date ended
Reason

                                                       Current
                                                        Age
Name of child 1
Name of child 2


                            Third Marriage                          Current residence or comments.
Name of spouse
Date started
Date ended
Reason

                                                       Current
                                                        Age
Name of child 1
Name of child 2


                Please describe your current living arrangements in the text box below.




(rev 3-27-03)

				
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