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DClinPsy Portfolio Volume 1 of 3 - University of Hertfordshire ...

DClinPsy Portfolio Volume 1 of 3 - University of Hertfordshire ...

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………………………………………………………………………………………….<br />

Is there a family history <strong>of</strong> mental illness? Please specify<br />

……………………………………….…………………………………………………<br />

………………………………………………………………………………………….<br />

Do you use any <strong>of</strong> the following?<br />

Non prescribed drugs<br />

Alcohol<br />

No Yes<br />

Have you experienced any <strong>of</strong> the following in your life? Please tick<br />

Move <strong>of</strong> house<br />

Move <strong>of</strong> school<br />

Loss <strong>of</strong> a family member or friend<br />

Parental separation<br />

Accident (e.g. car, fall). Please give<br />

details<br />

Illness. Please give details<br />

Bullying<br />

Hospitalisation. Please give details<br />

Other significant life event. Please<br />

circle:<br />

No Yes If yes, at<br />

what<br />

age(s)?<br />

e.g.<br />

physical<br />

assault<br />

unwanted<br />

sexual<br />

experience<br />

242

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