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

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.

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?