Personal Data Inventory Print PDF Form Step 1 of 6 16% Identification DataName(Required) First Last Phone(Required)Address(Required) Street Address Unit / Suite Number City State Zip Code Email Address(Required) Enter Email Confirm Email Occupation Business PhoneBirth Date Sex Male Female Age Marital StatusPlease Choose OneSingleEngagedMarriedSeparatedDivorcedRemarriedWidowEducationPlease Choose OneElementaryHigh SchoolGEDCollegeGraduateDegree Other Training (List type and years)HobbiesReferred to us by Relationship If 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 Occupation Spouse's PhoneSpouse's Age Spouse's Business PhoneSpouse's Religion Spouse's Education Does your spouse know you are coming for counseling? Yes No Is your spouse willing to come to counseling? Yes No Uncertain Have you ever been separated? Yes No When?FromTillYour ages when marriedHusbandWifeWedding DateHow long did you know your spouse before marriage? Length of steady dating with spouse Give brief information about any previous marriagesLength of engagement Information about childrenIs child is by a previous marriage? (Y/N)NameBirthdateSexLiving? (Y/N)Education (Y/N)Marital Status Add Remove History InformationHave you ever had a severe emotional upset? Yes No Have you ever had any psychotherapy or counseling before? Yes No List 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? Yes No Reason 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 Add RemoveWeight changes recentlyLostGained Add RemoveList all important present and past illnesses, injuries, or handicaps:Date of last medical examination What was the report? Name and address of your physicianAre you presently taking medication? Yes No Which medications? Have you used drugs for other than medical purposes? Yes No Which medications? Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports? Yes No Religious BackgroundDenominational preference What church do you attend? City Who is your pastor? May we contact your pastor for background information? Yes No What is the number of church services you attend per month?012345678910+Church attended in childhood Have you been baptized? Yes No Religious background of spouse Do you believe in God? Yes No Uncertain Do you pray to God? Yes No Occasionally Have 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? Yes No Uncertain Suppose you died today and God asked you “Why should I let you into my heaven?” What would you say?Are you saved? Yes No Uncertain How much do you read the Bible? Often Never Occasionally Does your family regularly read the Bible and pray together? Yes No Explain 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 Captcha Stay Updated Name* First Last Email* Captcha FollowFollowFollow
