Welcome to my couples Therapy services
If you want to make an appointment please call me under phone: +49 151/20933183
and bring the following questioner to the first session.
In order to understand you I need some information , so please fill this questionnaire.Your answers will save us valuable session time and improve my ability to be helpful to you. I assure you that brief answers are fine, but longer answers are also useful if you wish to provide more detail.
The information supplied is held in the strictest confidence and will not be disclosed to a third party without your express written consent
Date of Birth:
Married/Single/Divorced/In a relationship/etc:
Who lives with you?
Other significant people in your life:
What are your hopes/expectations of the therapy sessions with me?
Current state of health:
Any current or recent medical treatment?
Are you taking any medication? If so, please give details
Have you ever seen a psychiatrist? If so, please give details
Drinking: how many units of alcohol per week?
Smoking: how many per day?
Any other mood-altering substances?
When did the problem start?
What steps have you already taken to solve the problem, and with what results?
What stops you from changing?
What will be different once you have changed?
How will this change affect your family and friends?
What are the good things in your life at the moment (including any people that support you or activities that you enjoy)?
Any previous experience of therapy/counselling, positive or negative?
How did you find out about my services?
Of all the good things that could be said about your family, which one would you say is probably the most true and admirable?
What are the names and ages of each member of your family, including yourself?
What would you consider to be the most important things I should know and appreciate about each individual person in your family (including yourself)?
How do you see your family’s most positive qualities making it possible for you all to function better and deal with life’s big and small challenges?
Why do you suppose this problem hasn’t become worse than it already is?
*leave out if there are no children on either side of the relationship/problem
*Which child in the family is the most like you? How is he or she like you? What do you particularly enjoy about him or her ?)
*Who makes the big decisions for your family? Who makes the little, day-to-day, decisions for your family?
Which parent is most worried about the children? In what way?
*What is your philosophy about the best way to teach children?
*What is your philosophy on the best way to respond to children’s misbehavior?
*On what topics related to parenting situations do you and your partner have different opinions? What happens when you have different opinions on how to handle parenting situations?
*What other adults are important in the child’s life? In what way?
*What other children are important in the child’s life? In what way?
Describe the routine happenings on a typical weekday for your family.
What meals does your family eat together? How often? What are mealtimes like for your family?
What traumatic events have occurred during your child or your children’s lives? How did your child or your children react to the trauma? What was done to help your child or your children cope with any trauma they experienced?
What are your hopes and dreams for your child’s/children’s future?
About yourself : Please tell me a little bit about the family you grew up in:
How does your current family resemble the family you grew up in? How is your current family different from your family you grew up with?
How does your parenting resemble that of your parents? How is your parenting style different from theirs?
What else is important for me to know and appreciate about you and /include your family?
Thank you very much for answering all of these questions—
your responses are very helpful.
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Frau Lic. med. (RCH)
Ruth Helena Lueg
Fachärztin für innere Medizin
Zulassung für alle Krankenkassen und Privatkrankenkassen!
Termine nach Vereinbarung
Tel: +49 2822 70179
46446 Emmerich am Rhein