Demographics Questionnaire:
Name: ________________________________________
Date: ________________
01. Age: ____________
02. Gender: ____________
03. Which of the following best describes your race?
__ American Indian
__ Asian or Pacific Islander
__ African American
__ Caucasian
__ Other (please specify):_________________________
__ Prefer not to answer
04. Which of the following best describes your national origin or ancestry (check all that apply)?
__ Puerto Rican __ Chicano
__ Cuban __ Other Latin American
__ Mexican/Mexicano __ Other Spanish
__ Mexican American __ None of the above
05. What is the highest grade or year of regular school that you completed?
__ Never attended
__ Elementary School
__ Some High School
__ High School Diploma/GED
__ Some College
__ College Degree
__ Some Graduate or Professional School
__ Graduate or Professional Degree
06. I have been divorced for ___________?
__ less than one year
__ two to three years
__ four to five years
__ six to seven years
__ over eight years
07. Which of the following best describes your total combined household income
during the past 12 months?
___ $0-$14,999
___ $15,000-$34,999
___ $35,000-$54,999
___ $55,000-$84,999
___ $85,000 to 129,999
___ $130,000 or more
___ Decline to answer
08. What is your religious affiliation?
__ Protestant Christian
__ Roman Catholic
__ Evangelical Christian
__ Jewish
__ Muslim
__ Hindu
__ Buddhist
__ Other _________________________
09. How many years were you married?
__ (1-5)
__ (6-10)
__ (11-15)
__ (16-20)
__ (21-25)
__ (26-30)
__ (31 +)
10. To what do you attribute your marital discord? Check as many as apply.
__ Infidelity
__ Communication
__ Disagreement about child-rearing
__ Sexual Incompatibility/Dysfunction
__ Substance Use/Abuse
__ Work/Career Difficulties
__ Financial Difficulties
__ Mental Illness
__ Other
11. Are you currently living with your former spouse?
__ Yes
__ No
12. How many children do you have? _____________
13. If applicable, what are their ages? __________________________________
14. Did you receive marital counseling?
__ Yes Number of sessions? ______.
__ No
15. Did you receive individual counseling regarding your marital problems?
__ Yes Number of sessions? _______.
__ No
16. Did you receive group counseling regarding your marital problems?
__ Yes How many sessions? ______.
__ No
17. Please list any medications you may have taken before the marital problems.
_______________________________
_______________________________
18. Please list any medications you may have taken post marital problems.
______________________________
______________________________
19. If you are taking psychological medications, for how long?
__ 1-3 months
__ 4-6 months
__ 1 yr or more
20. Are you currently being treated by a physician for any physical illness?
__ Yes
__ No
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