Personal Data Inventory Print PDF Form Step 1 of 6 16% Identification DataName* First Last Phone*Address* Street Address Unit / Suite Number City State Zip Code Email Address* Enter Email Confirm Email OccupationBusiness PhoneBirth DateSexMaleFemaleAgeMarital StatusPlease Choose OneSingleEngagedMarriedSeparatedDivorcedRemarriedWidowEducationPlease Choose OneElementaryHigh SchoolGEDCollegeGraduateDegreeOther Training (List type and years)HobbiesReferred to us byRelationshipIf you were raised by anyone other than your own parents, briefly explainHow many siblings do you have?Older brothersOlder sistersYounger brothersYounger sisters Marriage InformationName of Spouse First Last Spouse's Address Street Address Unit / Suite Number City State Zip Code Spouse's OccupationSpouse's PhoneSpouse's AgeSpouse's Business PhoneSpouse's ReligionSpouse's EducationDoes your spouse know you are coming for counseling?YesNoIs your spouse willing to come to counseling?YesNoUncertainHave you ever been separated?YesNoWhen?FromTillYour ages when marriedHusbandWifeWedding DateHow long did you know your spouse before marriage?Length of steady dating with spouseGive brief information about any previous marriagesLength of engagementInformation about childrenIs child is by a previous marriage? (Y/N)NameBirthdateSexLiving? (Y/N)Education (Y/N)Marital Status History InformationHave you ever had a severe emotional upset?YesNoHave you ever had any psychotherapy or counseling before?YesNoList counselor or therapist and datesWhat was the outcome?Check off any of the following words which best describe you now active ambitious self confident persistent anxious hardworking impatient impulsive moody often sad excitable imaginative calm serious easy going shy fearful introvert extrovert likeable leader quiet inflexible submissive sensitive lonely self-conscious bitter angry Please check the appropriate box for any feelings you have felt any any time in the past Felt people were watching you? Had difficulty recognizing faces Been unable to judge distance Had visual hallucinations Had auditory (hearing) hallucinations List fears you haveHave you ever been arrested?YesNoReason Health InformationApproximately how many hours of sleep do you get each night?When do you go to sleep at night?When do you get up?Rate your health Very Good Good Average Declining Other Other (Health)Your approximateWeightHeight Weight changes recentlyLostGained List all important present and past illnesses, injuries, or handicaps:Date of last medical examinationWhat was the report?Name and address of your physicianAre you presently taking medication?YesNoWhich medications?Have you used drugs for other than medical purposes?YesNoWhich medications?Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports?YesNo Religious BackgroundDenominational preferenceWhat church do you attend?CityWho is your pastor?May we contact your pastor for background information?YesNoWhat is the number of church services you attend per month?012345678910+Church attended in childhoodHave you been baptized?YesNoReligious background of spouseDo you believe in God?YesNoUncertainDo you pray to God?YesNoOccasionallyHave you come to the place in your spiritual life where you can say that you know for certain that if you were to die today you would go to heaven?YesNoUncertainSuppose you died today and God asked you “Why should I let you into my heaven?” What would you say?Are you saved?YesNoUncertainHow much do you read the Bible?OftenNeverOccasionallyDoes your family regularly read the Bible and pray together?YesNoExplain any recent changes in your religious life, if any? Five Basic QuestionsBriefly answer the following questionsWhat are the issues you are struggling with?What have you done about it?What do you want us to do? (What are your expectations in coming here?)What circumstances led you to seek counsel here at this time?Is there any other information that would be we should know?Please type the characters shown Stay Updated Name* First Last Email* FollowFollowFollowFollow
