St. Louis Counseling Therapy at Change, Inc. – Depression Anxiety Couples Counseling

Change, Inc. St. Louis Counseling Therapy and Clayton Counseling and Psychotherapy Center provides care to individuals and couples – marriage and couples counseling, depression therapy, anxiety, addiction, relationship problems, anger, eating disorders, and other life-issues.

MMLHI

INFORMATION SUBMITTED ON THIS PAGE IS SECURE.

  1. The MultiModal Life History Inventory
  2. © 1991 by Arnold A. Lazarus and Clifford N. Lazarus
    This inventory has been placed online, but corresponds to purchased hard copies for each use.

  3. The purpose of this inventory is to obtain a comprehensive picture of your background. In psychotherapy, records are necessary since they permit a more thorough dealing with one's problems. By completing these questions as fully and accurately as you can, you will facilitate your therapeutic program. You are requested to answer these questions on your own time, rather than utilizing your actual session time. It is understandable that you may be concerned about the what happens to the information about you because much or all of this information is highly personal. Case records are strictly confidential, as per our Informed Consent Agreement.

  4. GENERAL INFORMATION
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  20. With whom do you live (check ALL that apply)?
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  29. PERSONAL & SOCIAL HISTORY
  30. Father:
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  34. Mother:
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  38. Siblings:

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  48. Check ANY of the following that apply regarding your childhood/adolescence:

  49. DESCRIPTION OF PRESENTING PROBLEMS
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  56. EXPECTATIONS REGARDING THERAPY
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  60. MODALITY ANALYSIS OF CURRENT PROBLEMS
  61. The following section is designed to help you describe your current problems in greater detail and to idenitify problems that might otherwise go unnoticed. This will enable us to design a comprehensive treatment program and tailor it to your specific needs. The following section is organized according to the seven modalities of Behaviors, Feelings, Physical Sensations, Images, Thoughts, Interpersonal Relationships, and Biological Factors.
  62. BEHAVIORS
  63. Check any of the following behaviors that apply to you:
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  71. FEELINGS
  72. Check any of the following feelings that often apply to you:
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  76. PHYSICAL SENSATIONS
  77. Check any of the following physical sensations that often apply to you:
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  80. IMAGES
  81. Check any of the following that apply to you:
  82. I picture myself:
  83. I have:
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  89. THOUGHTS
  90. Check each of the following that you might use to describe yourself:
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  94. On each of the following items, please select the number that most accurately reflects your opinion:
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  110. INTERPERSONAL RELATIONSHIPS
  111. Friendships
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  121. Marriage (or a committed relationship)
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  134. Sexual relationships
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  143. Other relationships
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  145. Please complete the following:
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  151. BIOLOGICAL FACTORS
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  159. Menstrual History
  160. Check any of the following that apply to you:
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  206. STRUCTURAL PROFILE
  207. Directions: Rate yourself on the following dimensions on a seven-point scale with "1" being the lowest and "7" being the highest.
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