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EAST-WEST PSYCHOTHERAPY SERVICE

150 Ishida-cho, Kamitakano, Sakyo-ku, Kyoto 606-0041

1-11-1 Yahataya, Minato-ku, Osaka 552-0014

075-781-2252 reggiepawle@yahoo.com 090-9982-5217

Reggie Pawle, Ph.D.
http://www.reggiepawle.net

Thank you for taking the time to complete this personal data summary. The purpose of this form is to obtain information about your background and your special concerns and needs that now affect your life. Please fill this form out as you see fit ? what does your therapist need to know?

Name_____________________________________ Age________ Sex M F Today’s Date______________________

Address_________________________________________________________________________________________

Home Phone_____________________ Keitai Phone _____________________ Email__________________________

OK to mention East-West Psychotherapy and/or me as your therapist when I call? Yes No

By whom were your referred? _______________________________________________________________________

What are the main concerns that bring you to therapy? ____________________________________________________

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What are your goals for therapy? _____________________________________________________________________

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PERSONAL HISTORY:

Nationality___________________ Education: Degree ______________ Date________ Where___________________

Occupation____________________ Employer___________________ How long?________ Work phone___________

FOR NON-JAPANESE - JAPAN HISTORY: Arrival Date______________ Date to Leave?_____________

Significant events in Japan__________________________________________________________________________

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SPOUSE/PARTNER RELATIONSHIP HISTORY:

Current Marital/Relationship Status_________________________ Married? Yes No If married, when__________

If not married, Living with You? _________ Beginning time of relationship ______________ Began in Japan Yes No

Describe your present relationship with your partner______________________________________________________

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What are your major challenges with your partner? ---------------------______________________________________________________

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Describe what you appreciate in your partner ___________________________________________________________

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# of pregnancies ________ # of live births ______

Children ____________________________________________ Age ________ Living with you? _______________

Any significant problems with your children? _________________________________________________________

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Previously married and divorced? ______ Previous significant relationships? ______ Dates ____________________

Please describe this (these) marriage(s) / relationship(s)__________________________________________________

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PARENTS: Mother ______________________________ Age _______ Living _______ If died, when? _______

Father _______________________________ Age _______ Living _______ If died, when? _______

Briefly describe your relationship with your parents as you were growing up ________________________________

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Were your parents ever separated? _____________ If so, for how long? _____________ How old were you? ______

With whom did you stay? ____________________ Did you ever live elsewhere than with your parents? __________

Where did you stay? ________________________ Briefly describe how that separation affected you _____________

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Were there any unusual or notable circumstances or events during your mother’s pregnancy (your in-utero

experience) and the time around your birth? ____________________________________________________________

SIBLINGS: Brothers (list ages) __________________________________________________________________

Sisters (list ages) ______________________________________________________________________

How would you describe your relationship with your siblings as you were growing up? ________________________

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FAMILY & PERSONAL SUBSTANCE-MENTAL HEALTH HISTORY:

Are you aware of any history of mental illness, alcoholism, or drug abuse in your family? ______ If yes, please

describe _______________________________________________________________________________________

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Do you have any history of mental illness? _____ If yes, please describe____________________________________

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Have you ever had a problem with or dependency on alcohol or drugs? ________ If yes, please describe __________

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What is your current use of alcohol or drugs? Please describe ____________________________________________

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Are you in a recovery program? ______ If so, how long have you been in recovery? __________________________

Please describe your recovery ______________________________________________________________________

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PHYSICAL HEALTH

Please describe your state of health and any physical problems you may have at this time ______________________

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List any long-term (chronic) health problems _________________________________________________________

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Are you under a physician’s care? Yes No Name of physician _________________________________________

Are you taking any medications? Please list __________________________________________________________

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What do you do to take care of yourself? _____________________________________________________________

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PLANS AND HOPES FOR FUTURE ? Please answer as you see fit -

What is important for your future? ___________________________________________________________________

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What are your plans ? goals ? hopes - dreams? _________________________________________________________

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Relationship plans ? goals ? hopes - dreams? __________________________________________________________

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Work plans ? goals ? hopes - dreams? ________________________________________________________________

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Where would you like to be living? ___________________________________________________________________

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What kind of a person would you like to be? ___________________________________________________________

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What would give meaning to your life? ________________________________________________________________

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Anything else regarding plans ? goals ? hopes - dreams? __________________________________________________

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PERSONAL PSYCHOLOGICAL ASSESSMENT

Please name three (3) descriptive adjectives that accurately express your character: (1) ________________________

(2) _____________________________________________ (3) ___________________________________________

What are your psychological strengths? ______________________________________________________________

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What are your psychological challenges?_____________________________________________________________

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Please try to state your biggest challenge or personal dilemma in a short phrase or question for yourself: ____________

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How have you attempted to investigate and/or improve yourself psychologically? ______________________________

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PREVIOUS COUNSELING

Name of Provider _______________________________ Dates ______________________ Frequency ____________

How strong is your desire for treatment? Very strong ________ Moderate _______ Can do without, if needed ______

Please add anything else you would like me to know about you: ____________________________________________

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THANK YOU