Personal Data Inventory First Name Last Name Email Address Primary Phone Secondary Phone Street Address Street Address 2 City State Postal / Zip Code Birthdate Age Occupation Employer How Long? Is your work fulfilling? Education - please select Education - please selectElementaryGEDHigh SchoolCollegeGraduate Degree Other Training (Please list type and years) Hobbies If you were raised by anyone other than your own parents, please explain: Do you have siblings? (Please explain) You are ... You are ... Male Female Are you married? Are you married? Yes Never been married Divorced Widowed How many children do you have? Please list children - Name, age, and indicate biological, step-child, adopted, or deceased Describe relationship with your father: Describe relationship with your mother: Describe your health: Do you have any chronic conditions? Do you have any chronic conditions? Yes No Date of Last Medical Exam Results of last medical exam: Current medication(s) and dosage: Recent Weight Changes? Lost? Gained? How many hours of sleep do you average each night? Is your sleep restful? What time do you normally go to bed? How long does it take you to fall asleep? What time do you wake up? Explain any recent changes. Have you ever used drugs for anything other than medical purposes? Have you ever used drugs for anything other than medical purposes? Yes No Have you ever been arrested? Have you ever been arrested? Yes No Do you drink alcoholic beverages? Do you drink alcoholic beverages? Yes No Do you drink coffee and/or other caffeine drinks? Do you drink coffee and/or other caffeine drinks? Yes No Do you smoke? Do you smoke? Yes No Have you ever had interpersonal problems on the job? Have you ever had interpersonal problems on the job? Yes No Have you ever had a severe emotional upset? Have you ever had a severe emotional upset? Yes No Have you ever seen a psychiatrist or a counselor? Have you ever seen a psychiatrist or a counselor? Yes No Denominational Preference: Church attending: Member? Member? Yes No Church attendance per month: Do you consider yourself a religious person? Do you believe in God? Do you believe in God? Yes No Do you pray? Do you pray? Yes No Would you say you are a Christian? Would you say you are a Christian? Yes No How often do you read your Bible? How often do you read your Bible? Never Occasionally Often Daily Explain any recent changes in your religious life: Please indicate to what degree (0 to 3) the issues below affect you. Please indicate to what degree (0 to 3) the issues below affect you.Please indicate to what degree (0 to 3) the issues below affect you. Abuse Abuse 0 1 2 3 Anger Anger 0 1 2 3 Anxiety Anxiety 0 1 2 3 Apathy Apathy 0 1 2 3 Appetite Appetite 0 1 2 3 Bitterness Bitterness 0 1 2 3 Change in Lifestyle Change in Lifestyle 0 1 2 3 Children Children 0 1 2 3 Communication Communication 0 1 2 3 Conflict (fights) Conflict (fights) 0 1 2 3 Deception Deception 0 1 2 3 Decision-making Decision-making 0 1 2 3 Depression Depression 0 1 2 3 Drunkenness Drunkenness 0 1 2 3 Envy Envy 0 1 2 3 Fear Fear 0 1 2 3 Finances Finances 0 1 2 3 Gluttony Gluttony 0 1 2 3 Grief Grief 0 1 2 3 Guilt Guilt 0 1 2 3 Health Health 0 1 2 3 Homosexuality Homosexuality 0 1 2 3 Impotence Impotence 0 1 2 3 Infertility Infertility 0 1 2 3 In-laws In-laws 0 1 2 3 Loneliness Loneliness 0 1 2 3 Lust Lust 0 1 2 3 Memory Memory 0 1 2 3 Moodiness Moodiness 0 1 2 3 Perfectionism Perfectionism 0 1 2 3 Pornography Pornography 0 1 2 3 Rebellion Rebellion 0 1 2 3 Sex Sex 0 1 2 3 Sleep Sleep 0 1 2 3 A Vice A Vice 0 1 2 3 Other Other 0 1 2 3 If 'A Vice' was selected above, please specify: If 'Other' was selected above, please specify: What is your problem (what brings you here)? What have you done about the problem? Is there any other information that we should know? Referred to us by: Relationship: Deliver to a particular counselor? Submit