Full Name:
Date:
Birthdate:
Interviewer:

1. Describe yourself briefly.BP, D
 

2. Describe your mother briefly.PI, CI
 

3. Describe your father briefly.PI, CI
 

4. What does your mother say when she compliments you?PI, CI, BP
(Use past tense if parents are deceased or no longer present in the client's life)
 

5. What does she say when she criticizes you?PI, CI, BP
 

6. What is her main advice to you?PI, CI, BP
 

7. What does your father say when he compliments you?PI, CI, BP
 

8. What does he say when he criticizes you?PI, CI, BP
 

9. What is his main advice to you?PI, CI, BP
 

10. What nicknames have people called you?  What BP do the names mean?
 

11. What do you want to be when you're an adult?D, C

12. What does your mother want you to be?PI, CI, BP
 

13. What does your father want you to be?PI, CI, BP
 

14. What do you like most about yourself?PI, CI, BP
 

15. What do you like least about yourself?PI, CI, BP
 

16. Do you ever feel that something might be wrong with you? BP (If yes, ask what.)
 

17. How many times have you gotten yourself in trouble?G
 

18. How do you usually go about getting yourself in trouble?G
 

19. Describe the bad feeling you have had most often in you life.R
 

20. When did you first feel it?D, BP
 

21. What was your favorite child story?P
 

22. What was you favorite part of it?P
 

23. If you continued to go along the way you are going? D How will things be different five years from today?
 

24. If you follow through on what you are now planning for C yourself, how will your life be five years from today?
 

25. How do you think you might die?  At what age?P, D
 

26. What will it say on your tombstone?D

27. What would Aheaven on earth be for you?D
 

28. What do you wish your mother had done differently?C
 

29. What do you wish your father had done differently?C
 

30. If by magic you could change anything about yourself, what would you change?D, C
 

31. What do you want most out of life?C
 

32. What is your biggest problem?C
 

33. Do you want to be sure before you complete counseling that you have made whatever decisions you have to
      make so that you will never have that problem again?C
 

34. What about yourselfCwill you change while you are completing counseling?C
 

35. What will you do while you are having counseling to make those changes?C
 

36. How will you and I both know that you have reached your goal?C
 

37. How will reaching that goal stop you from ever having that problem again?C
 
 
 

KEY:
BP = Basic Position
C = Contract
CI = Counterinjunction
D   = Decision
G = Game
P = Program
PI = Parental Injunction
R = Racket