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.

    NOTE: You MUST complete all boxes -- the assessment will not allow submissions that are incomplete in any way. If a section does not apply, please enter "n/a."

  4. GENERAL INFORMATION
  5. Required
  6. Email Required
  7. Required
  8. Required
  9. Required
  10. Required
  11. Required
  12. Required
  13. Required
  14. Required
  15. Required
  16. Required
  17. Required
  18. Required
  19. Required
  20. Required
  21. With whom do you live (check ALL that apply)?
  22. Required
  23. Required
  24. Required
  25. Required
  26. Required
  27. Required
  28. Required
  29. Required
  30. PERSONAL & SOCIAL HISTORY
  31. Parent/Guardian 1:
  32. Required
  33. Required
  34. Required
  35. Parent/Guardian 2:
  36. Required
  37. Required
  38. Required
  39. Siblings:

  40. Required
  41. Required
  42. Required
  43. Required
  44. Required
  45. Required
  46. Required
  47. Required
  48. Required
  49. Check ANY of the following that apply regarding your childhood/adolescence:

  50. DESCRIPTION OF PRESENTING PROBLEMS
  51. Required
  52. Required
  53. Required
  54. Required
  55. Required
  56. Required

  57. EXPECTATIONS REGARDING THERAPY
  58. Required
  59. Required
  60. Required

  61. MODALITY ANALYSIS OF CURRENT PROBLEMS
  62. 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.
  63. BEHAVIORS
  64. Check any of the following behaviors that apply to you:
  65. Required
  66. Required
  67. Required
  68. Required
  69. Required
  70. Required
  71. Required
  72. FEELINGS
  73. Check any of the following feelings that often apply to you:
  74. Required
  75. Required
  76. Required
  77. PHYSICAL SENSATIONS
  78. Check any of the following physical sensations that often apply to you:
  79. Required
  80. Required
  81. IMAGES
  82. Check any of the following that apply to you:
  83. I picture myself:
  84. I have:
  85. Required
  86. Required
  87. Required
  88. Required
  89. Required
  90. THOUGHTS
  91. Check each of the following that you might use to describe yourself:
  92. Required
  93. Required
  94. Required
  95. On each of the following items, please select the number that most accurately reflects your opinion:
  96. Required
  97. Required
  98. Required
  99. Required
  100. Required
  101. Required
  102. Required
  103. Required
  104. Required
  105. Required
  106. Required
  107. Required
  108. Required
  109. Required
  110. Required
  111. INTERPERSONAL RELATIONSHIPS
  112. Friendships
  113. Required
  114. Required
  115. Required
  116. Required
  117. Required
  118. Required
  119. Required
  120. Required
  121. Required
  122. Marriage (or a committed relationship)
  123. Required
  124. Required
  125. Required
  126. Required
  127. Required
  128. Required
  129. Required
  130. Required
  131. Required
  132. Required
  133. Required
  134. Required
  135. Sexual relationships
  136. Required
  137. Required
  138. Required
  139. Required
  140. Required
  141. Required
  142. Required
  143. Other relationships
  144. Required
  145. Please complete the following:
  146. Required
  147. Required
  148. Required
  149. Required
  150. Required

  151. BIOLOGICAL FACTORS
  152. Required
  153. Required
  154. Required
  155. Required
  156. Required
  157. Required
  158. Required
  159. Menstrual History
  160. Check any of the following that apply to you:
  161. Required
  162. Required
  163. Required
  164. Required
  165. Required
  166. Required
  167. Required
  168. Required
  169. Required
  170. Required
  171. Required
  172. Required
  173. Required
  174. Required
  175. Required
  176. Required
  177. Required
  178. Required
  179. Required
  180. Required
  181. Required
  182. Required
  183. Required
  184. Required
  185. Required
  186. Required
  187. Required
  188. Required
  189. Required
  190. Required
  191. Required
  192. Required
  193. Required
  194. Required
  195. Required
  196. Required
  197. Required
  198. Required
  199. Required
  200. Required
  201. Required
  202. Required
  203. Required
  204. Required
  205. Required

  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.
  208. Required
  209. Required
  210. Required
  211. Required
  212. Required
  213. Required

  214. Required
 

Tweet about this on TwitterShare on Facebook0Share on Google+0Share on LinkedIn0Email this to someone
Share St. Louis Counseling With Folks Who Need It!