Adult Social History Form

Please fill out Online or Download and bring in

Relationship Status
Name of Spouse/Partner
Occupation of Spouse/Partner

Family History

List your brothers, sisters and yourself, from oldest to youngest (include ages):

Interpersonal History

Please list your partners/spouses and your age when you were in the relationships:

Overall, how would you describe your relationship with your current partner/spouse:

List any children from oldest to youngest. Include their ages.

Educational History

Occupational History

How long have you worked at your present job?
Are you satisfied with your present job?
If not, what is the cause of your dissatisfaction?

Are you a veteran? If so, what branch of service?
Date of discharge were you involved in combat?

Socio-Cultural History

Were you raised in an:

Is your present home:

Legal History

If yes, what?

Have you been a victim of a crime?

Substance Abuse History

Sexual History

Trauma History

As a child, were you abused?
If yes, by whom?

As an adult, have you been abused?
If yes, by whom?

Have you been impacted by:
DeathDivorceSeparationOther Trauma
If yes, please describe.

Phone: 801.438.6059 | Fax: 801.501.0249

Draper Office

248 East 13800 South, #4
Draper, UT 84020

Bluffdale Office

14241 South Redwood Road Suite 100
Bluffdale, UT 84065