Family Inventory of Life Events and Changes Name * Client Number * 1. Increase of husband's/father's time away from family * Yes No 2. Increase of wife/mother's time away from family * Yes No 3. A member appears to have emotional problems * Yes No 4. A member appears to depend on alcohol or drugs * Yes No 5. Increase in conflict between husband and wife * Yes No 6. Increase in arguments between parent(s) and child(ren) * Yes No 7. Increase in conflict among children in the family * Yes No 8. Increased difficulty in managing teenage child(ren) * Yes No 9. Increased difficulty in managing school age child(ren) (6-12 years) * Yes No 10. Increased difficulty inmanaging preschool age child(ren) (2 1/2 - 6 years) * Yes No 11. Increased difficulty managing toddler(s) (1-2 1/2 years) * Yes No 12. Increased difficulty managing infant(s) (0-1 year) * Yes No 13. Increase in the amounts of "outside activities" which children are involved in * Yes No 14. Increased disagreement about a member's friends or activities * Yes No 15. Increase in the number of issues which don't get resolved * Yes No 16. Increae in the number of tasks or chores which don't get done * Yes No 17. Increased conflict with in-laws or relatives * Yes No 18. Spouse/parent are divorced or separated * Yes No 19. Spouse/parent had an affair * Yes No 20. Increased difficulty in resolving issues with a "former" or separated spouse * Yes No 21. Increased difficulty with sexual relationship between husband and wife * Yes No 22. Spouse has unwanted or difficult pregnancy * Yes No 23. An unmarried member becomes pregnant * Yes No 24. A member has an abortion * Yes No 25. A member gave birth to or adopted a child * Yes No 26. Took out a loan or refinanced a loan to cover increased expenses * Yes No 27. Went on welfare * Yes No 28. Change inconditions (political, weather) which hurts the family investments * Yes No 29. Change in agriculture market, stock market, or land values which hurts family investments and/or income * Yes No 30. A member started a new business * Yes No 31. Purchased or built a house * Yes No 32. A member purchased a car or other major item * Yes No 33. Increased financial strains due to over use of credit cards * Yes No 34. Increased strain on Family "money" for medical/dental expenses * Yes No 35. Increased strain on Family "money" for food, clothing, energy, home care * Yes No 36. Increased strain on Family "money" for child(ren)'s education * Yes No 37. Delay in receiving child support or alimony payments * Yes No 38. A member changed to a new job/career * Yes No 39. A member lost or quit a job * Yes No 40. A member retired from work * Yes No 41. A member started or returned from work * Yes No 42. A member stopped working for an extended period (e.g., laid off, leave of absence, strike) * Yes No 43. Decrease in satisfaction with job/career * Yes No 44. A member has increased difficulty with people at work * Yes No 45. A member was promoted at work or given more responsibilities * Yes No 46. Family moved to a new home or apartment * Yes No 47. A child/adolescent member changed to a new school * Yes No 48. Parent/spouse becomes seriously ill or injured * Yes No 49. Child becomes seriously ill or injured * Yes No 50. Close relative or friend of the family becomes ill * Yes No 51. A member becomes physically disabled or chronically ill * Yes No 52. Increased difficulty in managing a chronically ill or disabled member * Yes No 53. Member or close relative was committed to an institution or nursing home * Yes No 54. Increased responsibility to provide direct care or financial help to husband's and/or wife's parents * Yes No 55. Experienced difficulty in arranging for satisfactory child care * Yes No 56. A parent/spouse died * Yes No 57. A child member dies * Yes No 58. Death of husband's or wife's parent or close friend * Yes No 59. Close friend of the family died * Yes No 60. Married son or daughter separated or divorced * Yes No 61. A member "broke-up" a relationship with a close friend * Yes No 62. A member was married * Yes No 63. Young adult member left home * Yes No 64. Young adult member began college (or post high school training) * Yes No 65. A member moved back home or a new person moved into the house * Yes No 66. A parent/spouse started school (or training program) after being away from school for a long time * Yes No 67. A member went to jail or juvenile detention * Yes No 68. A member was picked up by police or arrested * Yes No 69. Physical or sexual abuse or violence in the home * Yes No 70. A member ran away from home * Yes No 71. A member dropped out of school or was suspended from school * Yes No Your Age * Sex * Nationality Number of people living in your family * Have you been in counseling before? * Yes No Ages of family members (Separate each with a comma) * Single Yes No Married Yes No Divorced Yes No Widowed Yes No Living Together Yes No Family Income: Under $20,000 Yes No Family Income: $20,000-40,000 Yes No Family Income: $40,000-60,000 Yes No Family Income: $60,000-80,000 Yes No Family Income: $90,000 and Above Yes No Are you a military family? * Yes No If Military, Pre-Deployment? Yes No If Military, Deployed? Yes No If Military, Post Deployment? Yes No If currently deployed Military, how long? If currently Post Deployment Military, how long? Church Attendance: Weekly? Yes No Church Attendance: Monthly? Yes No Church Attendance: Occasionally? Yes No Church Attendance: Rarely? Yes No Church Attendance: Never? 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