JENNIFER TARDELLI, MA, LPC, NCC PSYCHOTHERAPY WOMEN S ISSUES

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1 Personal History/Life Script Questionnaire What is your main reason for coming into therapy? What is your difficulty or personal problem? Give a recent example of when and how this problem occurred and how it impacted your life. Spell out in as much detail as possible the sequence of events and the outcome. What bad feelings went along with the occurrence of the problem? What did you say to yourself before, during and after this?

2 Do you remember a time in college, high school, middle school, elementary school or preschool when similar problems occurred? Are there other problems that you might be concerned about or that might be related? What is the thing about you you'd most like to change? How do you expect your main problem and most frequent bad feelings will change while you are in therapy? How do you expect the changes to occur?

3 How will you know when your therapeutic goals are achieved? What will be different in how you feel, how you act, in your life? Family history: Describe the current age or date of death, education, occupation and number of marriages of your mother, father, your siblings and yourself. Include stepparents if applicable. Be a kid and describe your mother as you saw her then: Be a kid and describe your father as you saw him then:

4 What information do you have about your birth? Your mother s pre-pregnancy? The family s circumstances? The kind of baby you were? What is the first thing you remember? What feelings were involved? What was your favorite myth, fairytale, Bible story etc. as a child? The one you wanted to hear over and over. Give the plot briefly. During adolescence and in the last two years, what were your favorite plays books movies etc. When you were a child what did your mother say when she criticized you? How did you respond or answer back in your head?

5 When you were a child what did your father say when he criticized you? How did you respond or answer back in your head? How did each parent praise you? Your response? What was your mothers main advice to you about how to live or get ahead? Your father? Your response? If you went to your mother now and told her in detail about your current problem how would she respond? How would your father respond?

6 What do you wish your mother had done differently? How would you be different as a result? What do you wish your father had done differently? How would you be different as a result? During grammar school who was the most important person to you other than your parents? What child was most important to you? What was the most important thing that happened to you in high school? Did you have any serious illness or injuries as a child or an adolescent?

7 Were you physically, emotionally or sexually abused as a child? What were the most traumatic experiences during your childhood? Since then? How did you decide on your present work? What first attracted you to your spouse or person you're most involved with at present? What made you decide to get married or live together if applicable.

8 Personal Describe yourself briefly. What do you like most about yourself? Least? If you were a magician how would you change you? What is the bad feeling you had most often in your life? If you make everything in your life go right from now on where will you be in five years? If you go on as you are now where will you be?

9 If everything goes wrong where will you be? How will you die? How old will you be?

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