Psychosexual Therapy Intake Form

Brothers and Sisters
(Psychosexual Therapy Intake Form)

How many siblings and what are the age differences?

Did anyone receive special attention (favourite or scapegoat)?

How did you get along then?

How do you get along now?

What were the sleeping arrangements?

Who was the most important person to you growing up?

Notes:

Other Circumstances
(Psychosexual Therapy Intake Form)

Any physical illness in the family?

Any mental or emotional difficulties?

Was religion important in your family?

Any house moves? Were they significant?

Notes:

Before Age 12
(Psychosexual Therapy Intake Form)

Your birth – straightforward or difficult?

Illnesses – were you ever hospitalised?

Stress symptoms (nail biting, bedwetting, nightmares, asthma, eczema)?

What kind of school did you attend first (single-sex/mixed)?

How did you like it? Did you get on with other children?

What did you learn about sex as a child (family/school/friends)?

Any unwanted sexual experiences?

Has this affected you? Did you have counselling?

Notes:

Adolescence
(Psychosexual Therapy Intake Form)

How was the transition to secondary school?

How did you get along with peers?

Were you happy with school performance?

Parents’ expectations of you?

What happened when you left school (education/work)?

Notes: