Description
For your workbook this week, you will reflect on the section of the Sexological Assessment on sex history. Then you will do the following:
Complete a journal assignment about the culture and environment you were raised in regarding topics related to sex and dating.
Identify professional development opportunities related to the topic of children and adolescent sex and sexuality that you could pursue for the Professional Development Assignment, due in Week 9.
Identify at least three resources to which you could refer child and adolescent clients for your Resource List.
Question:
Begin by reviewing the Sexological Assessment (Appendix C), a supplement to a general intakeassessment. Unlike an intake assessment, however, the Sexological Assessment is to be
reviewed gradually with clients to build an understanding of their holistic sexual being. Take the
time now to review the full assessment. While you are encouraged to answer the Sexological
Assessment questions for your own use, do not submit your answers to the Sexological
Assessment in this class. Submit your responses to the questions below.
1. What is it like to consider some of the questions from the Sexological Assessment for
yourself? (Note: Do not submit answers to the questions in the assessment; only describe how it felt
to consider the questions.)
2. Identify four sections from the Sexological Assessment you are most uncomfortable with. Write a
sentence or two per section considering why you are uncomfortable with this area of sex or
sexuality.
1.
2.
3.
4.
3. Explain at least 2 ethical implication(s) that you feel are most important for sexuality counseling
based on historical trends. Explain why you chose them and how they specifically apply to sexuality
counseling. Include a citation from the readings and the ACA Code of Ethics (2014).
Unformatted Attachment Preview
Appendix A: Sexological Assessment
Walden Counseling Sexological Assessment
This assessment is a supplemental assessment to the general assessment. This assessment does not include important
information needed when gathering client information. This assessment is to be completed across several sessions.
Client Name:
Today’s Date:
Legal Name:
Primary Language:
Cell Number:
House Number:
Is it okay to leave a voicemail? □ No □ Yes
Is it okay to leave a voicemail? □ No □ Yes
Date of Birth:
Self-Identified Gender:
Age:
Personal Pronoun (e.g., she, he, ze, they):
Address:
E-mail address:
INTRODUCTION
What brings you in to counseling at this time?
Symptoms
What are your current symptoms in order of what you find most bothersome:
1.
2.
3.
How are your symptoms affecting your ability to function at home? At work? In the community?
In what ways did your culture, ethnicity, or family background influence your values, beliefs, and attitudes
toward sex and sexuality? Consider whether religious or spiritual beliefs impacted your values, beliefs, and
attitudes.
What were your family’s attitudes toward sex? How was affection shown in your family?
HEALTH
How is your general health? Any chronic illnesses? Injuries? Past surgeries?
Mental Health History
Have you ever received a mental health diagnosis? □ No □ Yes
If yes, please list diagnosis/es and date(s) first diagnosed:
Have you ever been hospitalized for mental health concerns? □ No □ Yes
If yes, list date(s) and length of stay:
Have you ever or are you currently engaging in self-harm (such as cutting)?
Currently: □ No □ Yes
Past: □ No □ Yes
If yes, what type of self-harm and how often?
Have you ever experienced (if yes, please explain):
Extreme depressed mood: □ No □ Yes
Extreme mood swings: □ No □ Yes
Rapid speech: □ No □ Yes
Extreme anxiety: □ No □ Yes
Panic attacks: □ No □ Yes
Phobias: □ No □ Yes
Hallucinations: □ No □ Yes
Unexplained losses of time: □ No □ Yes
Unexplained memory lapses: □ No □ Yes
Eating disorder: □ No □ Yes
Repetitive behaviors (e.g., frequent checking, hand washing): □ No □ Yes
Homicidal thoughts: □ No □ Yes
Suicidal thoughts: □ No □ Yes
Suicide attempt: □ No □ Yes
Developmental History
Were there any complications with your birth? □ No □ Yes If so, please explain:
Did you reach developmental milestones within normal limits when you were a child (e.g., walking, talking)?
□ No □ Yes
Were you hospitalized for any accidents, illnesses, or high fever when you were a child? □ No □ Yes If yes,
explain:
Medical History (Include medications)
Please answer the following question using 5—Excellent, 4—Good, 3—Average, 2—Poor, 1—Failing
How would you currently rate your physical health?
Do you now have, or have you had in the past, any of the following? Check all that apply:
Now Past
Now Past
Now Past
Asthma
Allergies
Headaches
Brain Injury
Epilepsy
Seizures
Digestive Disorder
Cancer
Diabetes
Breathing Problems
Immune System
Heart Disease
High Blood Pressure
Vision Problems
Hearing Problems
Arthritis
Urinary Disorder
Tuberculosis
Thyroid Disorder
Multiple Sclerosis
Chronic Fatigue
Fibromyalgia
Pregnancy (how
many?)
Miscarriage (how many?)
Abortion (how many?)
STDs
Sleep Disorder
Serious Accident
Surgery
Other
Are you currently under the care of a medical doctor or other medical health professional: □ No □ Yes
Name of Primary Care Physician:
Physician Phone: ______________
Are you taking any prescription medications? □ No □ Yes If yes, please list:
List any over-the-counter medications, vitamins, or herbal supplements you are currently taking:
Do you currently exercise: □ No □ Yes If yes, please indicate what type and how many times per week:
Are you having any problems with your sleep habits? □ No □ Yes
If yes, check where applicable:
□ Sleeping too little □ Sleeping too much □ Poor-quality sleep □ Disturbing dreams □ Other
Are you having any difficulty with appetite or eating habits? □ No □ Yes
If yes, check where applicable: □ Eating less □ Eating more □ Binging □ Restricting
Have you experienced significant weight change in the last 2 months? □ No □ Yes
History of Substance Use
Please indicate substances currently used (over the past 6 months), how much at one time, how many
times per day/week, age of first use, past use history, and length of time used.
Substance
Alcohol
Tobacco
Marijuana
Ecstasy
Cocaine/Crack
Heroin
Methamphetamines
Other:
Current
Amount
Frequency
Age
Past
Length
Potential for Acute Intoxication, Withdrawal Problems, or Relapse
Have you ever believed your substance use was a problem for you? □ No □ Yes
Has anyone ever told you they believed your substance use was a problem? □ No □ Yes
Have you ever had withdrawal symptoms when trying to stop using any substances? □ No □ Yes
Have you ever had problems with work, relationships, health, or law due to your substance use? □ No □
Yes
If yes, please describe:
Sexual Health
How is your sexual health?
People with vulvas: Any menstrual difficulties? Fibroids? Ovarian cysts? When was your last
gynecological exam? Any abnormalities?
People with penises: Any discharge from penis during urination? Testicular cancer? When was
your last prostate check? Any abnormalities?
How do you feel about your body? What do you like and not like about your body?
How do you feel about your genitals? Have you looked at your genitals before? (If you have a vulva,
consider taking a mirror and looking between your legs in private.) How do you feel about touching
your genitals? If applicable, how do you feel about touching and observing your partner’s/partners’
genitals?
GENDER
At what age did you first become aware of your gender? ____
a. Did it coincide with your biological sex? How well did it conform to traditional gender expectations in
society and/or your family?
b. How do you identify your gender identity?
c. Do you currently have any discomfort with your gender identity?
AFFECTIONAL (SEXUAL) ORIENTATION
If applicable, when did you first become aware of your attraction to others?
Where are you on the following Scale of Desire and Affectional Orientation?
Orientation
G6
G5
G4
G3
G2
G1
G0
F6
F5
F4
F3
F2
F1
F0
E6
E5
E4
E3
E2
E1
E0
D6
D5
D4
D3
D2
D1
D0
C6
C5
C4
C3
C2
C1
C0
B6
B5
B4
B3
B2
B1
B0
A
A
A
A
A
A
A
Sexual Desire:
Affectional Orientation:
A (Aromantic/Asexuality): Experiences no romantic attraction or
sexual desire.
0: Exclusively attracted to those of the opposite
gender.
B (Romantic Asexuality): Not interested in sexual relations, but open
to romance, touch, or bonds stronger than friendship.
1: Mostly attracted to those of the opposite gender.
C (No Sexual Desire): Experiences no sexual desire, but willing to do it
for other reasons, such as children, pleasing their partners, and so
forth.
2: Prefers the opposite sex, but is also attracted to the
same gender.
3: Equal attraction to both.
D (Solitary Sexual Desire): Interested in masturbation but not in
engaging in sexual activity with others.
4: Prefers the same gender, but is also attracted to the
opposite gender.
E (Mid-Range Sexual Desire): Interested and/or engages in sexual
activity on a regular basis, either with others or alone.
5: Mostly attracted to the same gender.
6: Exclusively attracted to the same gender.
F (Strong Sexual Desire): Interested and/or engages in sexual activity
often, either with others or alone.
E (Very Strong Sexual Desire): Interested and/or engages in sexual
activity very often, either with others or alone.
Consider your response to the Scale of Desire and Affectional Orientation. How would you describe the sexual
desire you chose? For example, if you chose “E (Mid-Range Sexual Desire),” how would you describe this for
yourself?
Do you currently have any discomfort with affectional (sexual) orientation?
Do you or did you ever hide your affectional (sexual) orientation? If so, from whom?
SEX HISTORY
Family History (Include significant relationship history)
Were you adopted? □ No □ Yes If yes, your age at time of adoption:
With whom did you live until the age of 18? __________________________________________
Please list names, ages, and relationship (e.g., mother, father, daughter) of those in your self-described family.
Additionally, use the final column to indicate whether you have/had a positive relationship (+), negative
relationship (-), or neutral relationship (o) with the family member:
Name
Age
Relationship
Type of Relationship
1
2
3
4
5
6
Are your parents currently married/in a partnership? □ No □ Yes
Did your parents ever divorce? □ No □ Yes If yes, your age at time of divorce:
Were you ever in foster care or residential care? □ No □ Yes If yes, please list age and living situation:
Where did you live until the age of 18?
What is parent A’s current age? ___________ If deceased, your age at time of his/her death: ___________
What is parent B’s current age? ___________ If deceased, your age at time of his/her death: ___________
Other parent’s information here:
General Sex History
What messages did you receive about topics related to sex and dating, such as masturbation or premarital sex,
as a child?
At what age did you begin puberty? Was this earlier, later, or about the same time as your peers?
Did you have accurate information about what would happen in puberty? □ No □ Yes
Did you have someone you felt comfortable asking questions about puberty? □ No □ Yes
If applicable, how do you or would you ideally raise children related to sex and sexuality? Any similarities or
differences as to how you were raised?
HEALTHY SEXUAL FUNCTIONING
If applicable, when did you first discover masturbation? Age: _______
•
What was your reaction to this?
•
Were there ever any embarrassing issues related to masturbation?
•
Do you continue to masturbate? If so, how often? If not, why?
•
Is there currently anything about masturbation that concerns you?
If applicable, when did you first begin climaxing/orgasming?
•
What was your reaction to this?
•
Were there ever any embarrassing issues related to orgasm?
Do you currently have orgasms? If so, what percentage of the time? If not, what are the reasons why?
•
In what ways can you experience orgasm (e.g., stimulation, oral sex, penetrative)?
•
Are you able to have multiple orgasms?
•
Have you ever faked an orgasm?
•
Is there currently anything about having orgasms, or not having orgasms, that concerns you?
Are you currently in a relationship(s)? □ No □ Yes
Name of person(s): ________________________
Length of time you have known each other:___________ Length of time together: ________
Do you currently live together? □ No □ Yes
Number of significant relationships: _________ Number of divorces: _________
SEXUAL DYSFUNCTION
Have you ever been diagnosed with a sexually transmitted infection/disease or HIV? If so, how old were you?
From whom did you get it? What was your reaction to it?
Are you experiencing, or have you ever experienced, any of the following?
Always
Sometimes
Pain during sexual activity
Inability to orgasm
Orgasm too quickly
Lack of desire
Unable to lubricate
Unable to achieve or maintain an erection
Involuntary contraction of the vagina preventing penetration
Intense fear of sexual contact or thoughts about sexuality
PLEASURE AND SEXUAL LIFESTYLES
How often do you have sexual fantasies?
a. Briefly describe your fantasies.
b. Are you comfortable with the content of your fantasies? □ No □ Yes
Have you or your partner(s) engaged in sexual fantasies? Describe.
Have you ever engaged in sexual behavior that you worried about or knew was illegal?
Never
N/A
Mark where you are based on your amorous expression:
SEXUAL EXPLOITATION
Have you ever had any negative or upsetting sexual experiences? □ No □ Yes
How old were you? What effect has it had on you? What was the experience(s)?
Have you ever told anyone about this? If so, who? If not, why?
Trauma History
Please indicate whether you or a member of your immediate family experienced any of the following. If a
family member, please indicate relationship(s):
Event
Emotional Abuse
Physical Abuse
Sexual Abuse
Domestic Violence
Neglect
Substance Abuse
Serious Illness
Accident or Injury
Self
Other Relationship
Event
Self
Legal Problems
Frequent/Multiple Moves
Homelessness
Financial Problems
Lived Overseas
Military Member
Discrimination
Other
Other Relationship
OTHER ISSUES RELATED TO SEX AND SEXUALITY
Pregnancy
Have you ever been pregnant or gotten someone else pregnant? □ No □ Yes
Was this planned on unplanned? What was/were the outcome(s) of the pregnancy?
If you ever had children, how did you they affect your sexuality?
Have you ever struggled with infertility? □ No □ Yes
If yes, please share when.
Pornography
At what age were you exposed to pornography if you have been exposed? _____
What was your reaction? How much, if any, do you currently use/view pornography? Do you have any
concerns about the amount of time you spend watching pornography or any concerns about the content you
view?
Strengths and Interests
What are your strengths and interests?
Goals
What are the goals you hope to achieve in counseling:
1.
2.
3.
Is there anything you would like to add that I have not asked and that you would like to include?
Client Signature: ___________________________ Date: ___________________
Thank you for your time! Please contact me with any questions.
1
Appendix B: Sexological Assessment for School Settings
Walden Counseling Sexological Assessment
NOTE: This assessment is a supplemental assessment to the general assessment. This assessment does not include
important information needed for gathering client information. This assessment is to be completed across several
sessions.
The language used in this assessment may need to be altered based on the age of your client. Please do not hand this
assessment to your client. Instead, pick and choose certain sections and adjust the language to meet the appropriate
developmental stage of your client.
Client Name:
Today’s Date:
Legal Name:
Primary Language:
Cell Number:
House Number:
Is it okay to leave a voicemail? □ No □ Yes
Is it okay to leave a voicemail? □ No □ Yes
Date of Birth:
Age:
Personal Pronoun (e.g., she, he, ze, they):
Are you a minor? □ No □ Yes
Do your legal guardians/parents/caregivers know
that you are in counseling? □ No □ Yes
Self-Identified Gender:
Address:
E-mail address:
INTRODUCTION
What brings you in to counseling at this time?
Symptoms
What are your current symptoms in order of what you find most bothersome:
1.
2.
3.
How are your symptoms affecting your ability to function at home? At school?
Share a bit about your culture.
What are your family’s/guardian’s/caregiver’s attitudes toward intimacy and sex?
2
HEALTH
How is your general health? Any chronic illnesses? Injuries? Past surgeries?
Mental Health History
Have you ever received a mental health diagnosis? □ No □ Yes
If yes, please list diagnosis/es and date(s) first diagnosed:
Have you ever been hospitalized for mental health concerns? □ No □ Yes
If yes, list date(s) and length of stay:
Have you ever or are you currently engaging in self-harm (such as cutting)?
Currently: □ No □ Yes
Past: □ No □ Yes
If yes, what type of self-harm and how often?
Have you ever experienced (if yes, please explain):
Extreme depressed mood: □ No □ Yes
Extreme mood swings: □ No □ Yes
Rapid speech: □ No □ Yes
Extreme anxiety: □ No □ Yes
Panic attacks: □ No □ Yes
Phobias: □ No □ Yes
Hallucinations: □ No □ Yes
Unexplained losses of time: □ No □ Yes
Unexplained memory lapses: □ No □ Yes
Eating disorder: □ No □ Yes
Repetitive behaviors (e.g., frequent checking, hand washing): □ No □ Yes
Homicidal thoughts: □ No □ Yes
Suicidal thoughts: □ No □ Yes
Suicide attempt: □ No □ Yes
Developmental History
Were there any complications with your birth? □ No □ Yes If so, please explain:
3
Did you reach developmental milestones within normal limits when you were a child (e.g., walking, talking)?
□ No □ Yes
Were you hospitalized for any accidents, illnesses, or high fever when you were a child? □ No □ Yes If yes,
explain:
Medical History (Include medications)
Please answer the following question using 5—Excellent, 4—Good, 3—Average, 2—Poor, 1—Failing
How would you currently rate your physical health?
Do you now have, or have you had in the past, any of the following? Check all that apply:
Now Past
Now Past
Now Past
Asthma
Allergies
Headaches
Brain Injury
Epilepsy
Seizures
Digestive Disorder
Cancer
Diabetes
Breathing Problems
Immune System
Heart Disease
High Blood Pressure
Vision Problems
Hearing Problems
Arthritis
Urinary Disorder
Tuberculosis
Thyroid Disorder
Multiple Sclerosis
Chronic Fatigue
Fibromyalgia
Pregnancy (how
many?)
Miscarriage (how many?)
Abortion (how many?)
STDs
Sleep Disorder
Serious Accident
Surgery
Other
Are you currently under the care of a medical doctor or other medical health professional: □ No □ Yes
Name of Primary Care Physician:
Physician Phone: ______________
Are you taking any prescription medications? □ No □ Yes If yes, please list:
List over-the-counter medications, vitamins, or herbal supplements you are currently taking:
4
Do you currently exercise: □ No □ Yes If yes, please indicate what type and how many times per week:
Are you having any problems with your sleep habits? □ No □ Yes
If yes, check where applicable:
□ Sleeping too little □ Sleeping too much □ Poor-quality sleep □ Disturbing dreams □ Other
Are you having any difficulty with appetite or eating habits? □ No □ Yes
If yes, check where applicable: □ Eating less □ Eating more □ Binging □ Restricting
Have you experienced significant weight change in the last 2 months? □ No □ Yes
History of Substance Use
Please indicate substances currently used (over the past 6 months), how much at one time, how many
times per day/week, age of first use, past use history, and length of time used.
Substance
Alcohol
Tobacco
Marijuana
Ecstasy
Cocaine/Crack
Heroin
Methamphetamines
Other:
Current
Amount
Frequency
Age
Past
Length
Potential for Acute Intoxication, Withdrawal Problems, or Relapse
Have you ever believed your substance use was a problem for you? □ No □ Yes
Has anyone ever told you they believed your substance use was a problem? □ No □ Yes
Have you ever had withdrawal symptoms when trying to stop using any substances? □ No □ Yes
Have you ever had problems with work, relationships, health, or law due to your substance use? □ No □
Yes
If yes, please describe:
5
Sexual Health
How is your sexual health?
People with vulvas: Any menstrual difficulties? Fibroids? Ovarian cysts? When was your last
gynecological exam? Any abnormalities?
People with penises: Any discharge from penis during urination? Testicular cancer? When was
your last prostate check? Any abnormalities?
How do you feel about your body? What do you like and not like about your body?
How do you feel about your genitals? Have you looked at your genitals before? (If you have a vulva,
consider taking a mirror and looking between your legs in private). How do you feel about touching
your genitals? If applicable, how do you feel about touching and observing your partner’s/partners’
genitals?
6
GENDER
At what age did you first become aware of your gender? ____
a. Did it coincide with your biological sex? How well did it conform to traditional gender expectations in
society and/or your family?
b. How do you identify your gender identity?
c. Do you currently have any discomfort with your gender identity?
7
AFFECTIONAL (SEXUAL) ORIENTATION
If applicable, when did you first become aware of your attraction to others?
Where are you on the following Scale of Desire and Affectional Orientation?
Orientation
G6
G5
G4
G3
G2
G1
G0
F6
F5
F4
F3
F2
F1
F0
E6
E5
E4
E3
E2
E1
E0
D6
D5
D4
D3
D2
D1
D0
C6
C5
C4
C3
C2
C1
C0
B6
B5
B4
B3
B2
B1
B0
A
A
A
A
A
A
A
Sexual Desire:
Affectional Orientation:
A (Aromantic/Asexuality): Experiences no romantic attraction or
sexual desire.
0: Exclusively attracted to those of the opposite
gender.
B (Romantic Asexuality): Not interested in sexual relations, but open
to romance, touch, or bonds stronger than friendship.
1: Mostly attracted to those of the opposite gender.
C (No Sexual Desire): Experiences no sexual desire, but willing to do it
for other reasons, such as children, pleasing their partners, and so
forth.
2: Prefers the opposite sex, but is also attracted to the
same gender.
3: Equal attraction to both.
D (Solitary Sexual Desire): Interested in masturbation but not in
engaging in sexual activity with others.
4: Prefers the same gender, but is also attracted to the
opposite gender.
E (Mid-Range Sexual Desire): Interested and/or engages in sexual
activity on a regular basis, either with others or alone.
5: Mostly attracted to the same gender.
F (Strong Sexual Desire): Interested and/or engages in sexual activity
often, either with others or alone.
E (Very Strong Sexual Desire): Interested and/or engages in sexual
activity very often, either with others or alone.
6: Exclusively attracted to the same gender.
8
Consider your response to the Scale of Desire and Affectional Orientation. How would you describe the sexual
desire you chose? For example, if you chose “E (Mid-Range Sexual Desire),” how would you describe this for
yourself?
Do you currently have any discomfort with affectional (sexual) orientation?
Do you or did you ever hide your affectional (sexual) orientation? If so, from whom?
SEX HISTORY
Family History (Include significant relationship history)
Were you adopted? □ No □ Yes If yes, your age at time of adoption:
With whom did you live until the age of 18? __________________________________________
Please list names, ages and relationship (e.g., mother, father, daughter) of those in your self-described family.
Additionally, use the final column to indicate whether you have/had a positive relationship (+), negative
relationship (-), or neutral relationship (o) with the family member:
Name
1
2
3
4
Age
Relationship
Type of Relationship
9
5
6
Are your parents currently married/in a partnership? □ No □ Yes
Did your parents ever divorce? □ No □ Yes If yes, your age at time of divorce:
Were you ever in foster care or residential care? □ No □ Yes If yes, please list age and living situation:
Where did you live until the age of 18?
What is parent A’s current age? ___________ If deceased, your age at time of his/her death: ___________
What is parent B’s current age? ___________ If deceased, your age at time of his/her death: ___________
Other parent’s information here:
General Sex History
What messages have you heard about topics related to sex and dating, such as masturbation or premarital
sex?
If you have, at what age did you begin puberty? Was this earlier, later, or about the same time as your peers?
Do you have accurate information about what would happen in puberty? □ No □ Yes
Do you have someone you feel comfortable asking questions about puberty? □ No □ Yes
HEALTHY SEXUAL FUNCTIONING
If applicable, when did you first discover masturbation? Age: _______
•
What was your reaction to this?
•
Were there ever any embarrassing issues related to masturbation?
•
Do you continue to masturbate? If so, how often? If not, why?
•
Is there currently anything about masturbation that concerns you?
10
If applicable, when did you first begin climaxing/orgasming?
•
What was your reaction to this?
•
Were there ever any embarrassing issues related to orgasm?
Do you currently have orgasms? If so, what percentage of the time? If not, what are the reasons why?
•
In what ways can you experience orgasm (e.g., stimulation, oral sex, penetrative)?
•
Are you able to have multiple orgasms?
•
Have you ever faked an orgasm?
•
Is there currently anything about having orgasms, or not having orgasms, that concerns you?
Are you currently in a relationship(s)? □ No □ Yes
Name of person(s): ________________________
Length of time you have known each other:___________ Length of time together: ________
Do you currently live together? □ No □ Yes
Number of significant relationships: _________ Length of time together: ________
SEXUAL DYSFUNCTION
Have you ever been diagnosed with a sexually transmitted infection/disease or HIV? If so, how old were you?
From whom did you get it from? What was your reaction to it?
Are you (or have you ever) experienced any of the following?
Always
Pain during sexual activity
Inability to orgasm
Orgasm too quickly
Lack of desire
Unable to lubricate
Unable to achieve or maintain an erection
Involuntary contraction of the vagina preventing penetration
Intense fear of sexual contact or thoughts about sexuality
Sometimes
Never
N/A
11
PLEASURE AND SEXUAL LIFESTYLES
How often do you have sexual fantasies?
a. Briefly describe your fantasies.
b. Are you comfortable with the content of your fantasies? □ No □ Yes
Have you or your partner(s) engaged in sexual fantasies? Describe.
Have you ever engaged in sexual behavior that you worried about or knew was illegal?
SEXUAL EXPLOITATION
Have you ever had any negative or upsetting sexual experiences? □ No □ Yes
How old were you? What effect has it had on you? What was the experience(s)?
Have you ever told anyone about this? If so, who? If not, why?
Trauma History
Please indicate whether you or a member of your immediate family experienced any of the following. If a
family member, please indicate relationship(s):
Event
Emotional Abuse
Physical Abuse
Sexual Abuse
Domestic Violence
Neglect
Substance Abuse
Serious Illness
Accident or Injury
Self
Other Relationship
Event
Self
Legal Problems
Frequent/Multiple Moves
Homelessness
Financial Problems
Lived over-seas
Military member
Discrimination
Other
OTHER ISSUES RELATED TO SEX AND SEXUALITY
Pregnancy
Have you ever been pregnant or gotten someone else pregnant? □ No □ Yes
Was this planned on unplanned? What was/were the outcome(s) of the pregnancy?
Other Relationship
12
If you ever had children, how did you they affect your sexuality?
Pornography
If applicable, at what age were you exposed to pornography if you have been exposed? _____
What was your reaction? How much, if any, do you currently use/view pornography? Do you have any
concerns about the amount of time you spend watching pornography, or any concerns about the content you
view?
Strengths and Interests
What are your strengths and interests?
Goals
What are the goals you hope to achieve in counseling:
1.
2.
3.
Is there anything you would like to add that I have not asked which you would like to include?
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