Lifestyle Assessment Form Adlerian PDF Details

The Lifestyle Assessment Adlerian form, as designed by prominent professionals Robert G. Bartholow, MSW, Robert G. Willhite, MSW, and Susan Pye Brokaw, MA from the Adler Graduate School, is a comprehensive tool that dives deep into an individual's early familial and personal milieu to unearth fundamental aspects of their psyche and behavioral patterns. This form meticulously covers a vast array of areas including, but not limited to, family constellation—which details family members and their dynamics, sexual and physical development, and a series of childhood to adult experiences ranging from dreams and fears to ambitions and early recollections. The assessment guides the completing individual through a reflective journey, asking them to consider various aspects of their upbringing, such as their perceptions of their parents, sibling relationships, and significant adult influences, along with pivotal developmental milestones and experiences. This structured yet introspective inquiry offers a detailed lens into the respondent's past, aiming to shed light on the underlying factors that influence their current lifestyle choices and psychological disposition. With its rich, detailed prompts and thoughtprovoking questions, the Adlerian form stands as a key instrument in understanding the complexity of human behavior and the varied paths that lead to adulthood, invoking a deep analysis of the self within the familial and social context.

QuestionAnswer
Form NameLifestyle Assessment Form Adlerian
Form Length17 pages
Fillable?No
Fillable fields0
Avg. time to fill out4 min 15 sec
Other namesadlerian lifestyle assessment, adlerian lifestyle assessment pdf, adler lifestyle assessment questionnaire, assessment form adlerian

Form Preview Example

ADLER GRADUATE SCHOOL

 

Lifestyle Assessment

 

by Robert G. Bartholow, MSW, Robert G. Willhite, MSW, Susan Pye Brokaw,MA

 

 

Table of Contents

 

Table of Contents

1

I.

Family Constellation

2

A.

Members of your family of origin: (Enter Name of Your Mother and Father)

2

B.

Children (Include brothers and sisters and self, in order of birth. Also indicate

 

 

miscarriages, stillborn, and deceased siblings.)

2

C.

Data on client as a child:

3

D.

Sibling Interrelationships:

5

E.

Description of your parents, as seen by you when you were a child:

5

F.

Additional adult figures who had a significant influence on your childhood

9

II.

Sexual and Physical Development

9

A.

Sexual development:

9

B.

Physical Development:

10

III.

Childhood Dreams:

10

IV.

Childhood Fears:

10

V.

Childhood Ambitions:

10

VI.

Adult Dreams:

10

VII.

Three Wishes at This Point in Time

11

VIII.

Early Recollections

12

Summary Statements

13

© 2006 Adler Graduate School

May be reproduced in its original form as long as this copyright notice is included

Adler Graduate School

Lifestyle Assessment

Client’s Name

Date

Therapist

I.Family Constellation

A. Members of your family of origin:

Name

Father

 

Mother

 

 

 

B.Children (Include brothers and sisters and self, in order of birth. Also indicate miscarriages, stillborn, and deceased siblings.)

Insert Genogram below

Revised 1/2006

2

Adler Graduate School

Lifestyle Assessment

Give childhood descriptions of each child, in birth order, including self

Name

Brief Description

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.Data on client as a child:

1Who was most like you? In what ways?

2Who was most different from you?

In what ways?

3Grade school information: Attitude?

Favorite subject? Least liked subject? Social situation? Teachers pet?

4Sports interests or skills?

5Childhood habits?

6When a child, who had health problems, physical or emotional?

7*

As a child, did you feel

 

 

that boys or girls had

 

 

advantages over the

 

 

other?

 

 

 

Revised 1/2006

3

 

Adler Graduate School

 

 

 

 

 

Lifestyle Assessment

 

 

 

 

 

 

 

 

 

 

 

 

8*

If a female, were you a

 

 

 

 

 

 

 

tomboy in childhood?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9*

If male, did you personally

 

 

 

 

 

 

 

think of yourself as a

 

 

 

 

 

 

 

sissy?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10

Childhood spiritual or

 

 

 

 

 

 

 

religious experiences, if

 

 

 

 

 

 

 

any?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11

Did you, or any family

Emotional

 

Physical

 

Sexual

 

 

member(s), experience any

 

 

 

 

 

 

 

abuse (within or outside

 

 

 

 

 

 

 

the family)?

 

 

 

 

 

 

 

 

Yes

 

Yes

 

Yes

 

 

 

No

 

No

 

No

 

 

If so:

 

 

 

 

 

 

 

to whom?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

By whom?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Elaborate?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12

Who was most spoiled?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

By whom?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How and for what reason?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13

Who was most punished?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

By whom?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How and for what reason?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14

Who in the family needed

 

 

 

 

 

 

 

to be right?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15

Who in the family felt keen

 

 

 

 

 

 

 

about fairness and

 

 

 

 

 

 

 

unfairness?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16

Your role in peer group?

 

 

 

 

 

 

 

(leader, middler, follower,

 

 

 

 

 

 

 

outsider)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17

Childhood talents or

 

 

 

 

 

 

 

accomplishments?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18

Your parent’s method of

 

 

 

 

 

 

 

disciplining?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised 1/2006

4

 

 

 

 

 

Adler Graduate School

Lifestyle Assessment

1

2

3

4

5

6

D.Sibling Interrelationships: Who took care of whom?

Who played with whom?

Who got along best with whom?

Who fought and argued most?

Who was helpful at home?

Who made mischief?

E.Description of your parents, as seen by you when you were a child:

FatherMother

Current age if living

If deceased

Age when client born

Education

Occupation

Personality: traits admired, liked, disliked, feared

What was most important to them?

What behavior or attitude could win their praise?

What made them angry?

What ways did they influence you?

What were their expectations of the children?

Revised 1/2006

5

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Put the asked information in the Give childhood descriptions of, Brief Description, Data on client as a child, C Who was most like you, In what ways, and Who was most different from you In segment.

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Point out the main information about the Who was most different from you In, Grade school information Attitude, Favorite subject, Least liked subject, Social situation, Teachers pet, Sports interests or skills, Childhood habits, When a child who had health, and As a child did you feel that boys segment.

form adlerian Who was most different from you In, Grade school information Attitude, Favorite subject, Least liked subject, Social situation, Teachers pet, Sports interests or skills, Childhood habits, When a child who had health, and As a child did you feel that boys fields to fill out

The Adler Graduate School Lifestyle, Emotional, Physical, Sexual, Yes No, Yes No, Yes No, If a female were you a tomboy in, If male did you personally think, Childhood spiritual or religious, Did you or any family members, If so to whom, By whom, and Elaborate field will be your place to place the rights and responsibilities of all parties.

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Finalize by looking at all of these fields and filling in the proper information: Who was most spoiled, By whom, How and for what reason, Who was most punished, By whom, How and for what reason, Who in the family needed, to be right, Who in the family felt keen about, and Your role in peer group leader.

Who was most spoiled, By whom, How and for what reason, Who was most punished, By whom, How and for what reason, Who in the family needed, to be right, Who in the family felt keen about, and Your role in peer group leader in form adlerian

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