MFT Psychosocial History Form
Please complete the MFT Psychosocial History Form below. If you have any questions, please email firstname.lastname@example.org.
Applicant Email Address
Which program are you applying to?
Your Background and Experiences
How is the degree in Marriage and Family Therapy the next step in your professional/ministry growth?
How are you currently using your counseling attributes/talents?
Have you ever been in any type of psychotherapy? If so, please describe the
purpose, duration, placement, type and outcome of that treatment. Was this in or
out-patient treatment? Are you currently on any type of psychoactive
medication? (Name and dosage)
From what traumatic events, such as abuse, violence, chemical dependence,
divorce, or depression have you, your spouse, your child, or your parents
Briefly describe your goals for emotional, spiritual, and interpersonal growth
during the next few years:
Have you ever been arrested and/or convicted for sexual, drug/alcohol, or violent
conduct? If so, provide dates and outcome of hearings or trials. Have you ever
been convicted of felony? If so, provide dates and outcome of hearing or trials.
Signature & Acknowledgement
I certify that the foregoing information is true and correct. I understand that my giving false or misleading information regarding my psychosocial history is grounds for denial of admission, or dismissal from the program after admission.
By checking this box, I agree
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