Personal Data Inventory

PERSONAL DATA INVENTORY

IDENTIFICATION DATA Date: ______

Name: ______Home Phone: ( ____ ) ______- ______Cell Phone: ( ____ ) ______- ______Email Address: ______Address:______Sex: _____ Age: ___ Date of Birth: ______(Street) (City) (State) (Zip) Referred for counseling by: ______PERSONAL HISTORY Parents: Name Age (if living) Occupation Marital Status *(M,S,D.) Father: ______How would you rate your relationship with him? □ Outstanding, □ Excellent, □ Good, □ OK, □ Full of problems, □ Miserable Mother:______How would you rate your relationship with her? □ Outstanding, □ Excellent, □ Good, □ OK, □ Full of problems, □ Miserable

Siblings: Name Age Relationship Marital Status *(M,S,D.) ______*Married, Single, Divorce If you were reared by anyone other than your own parents please explain: ______Indicate which might have applied during your childhood and/or adolescence: □ School problems, □ Family problems, □ Medical problems, □ Drug/Alcohol abuse problems, □ Social problems, □ Legal problems Please explain: ______Have you ever been arrested? □ Yes / □ No Reason: ______EDUCATION □ Elementary □ High School □ College □ Graduate School □ Other ______OCCUPATIONAL HISTORY Occupation: ______Company: ______Company Address: ______Phone: ( ____ ) _____ - ______Years there ______What other jobs have you held in the past? ______Does your present work satisfy you? □ Yes / □ No If no, please explain. ______

1 Hobbies: ______

MARRIAGE AND FAMILY INFORMATION Marital Status: □ Single, □ Engaged, □ Married, □ Remarried, □ Separated, □ Divorced, □ Widowed If married, Spouse's name: ______Age: _____ Occupation: ______Length of dating prior to marriage: ______. Give a brief statement of circumstances of meeting and dating ______Spouse's religious background: ______Education: ______Date of marriage: ______Will your spouse be coming to counseling? □ Yes / □ No Have you ever been separated from your present spouse? □ Yes / □ No If yes, please specify when: 1) ______to ______2) ______to ______Children: Name Relationship At Home? Age Marital Status Occupation *PM ______* Check PM column if child is by previous marriage. Your Previous Marriages (if applicable) Dates Reason for the end of this marriage ______to ______to ______Spouse's Previous Marriages (if applicable) Dates Reason for the end of this marriage ______to ______to ______How would you rate your current marriage? □ Outstanding, □ Excellent, □ Good, □ OK, □ Full of problems, □ Miserable RELIGIOUS BACKGROUND Denominational preference______Church presently attending: ______Address: ______Pastor: ______May we consult with him? □ Yes / □ No Number of weekend services you attend per month: ______Do you believe in God? □ Yes / □ No / □ Uncertain Do you pray? ___ never, ___ occasionally, ___ often, ___ daily Do you read the Bible? ___ never ___ occasionally ___ often ___ daily Would you say you are a Christian? □ Yes / □ No If so, when did it happen? ______Or would you say you are still in the process of becoming a Christian? □ Yes / □ No Do you consider yourself "saved"? □ Yes / □ No / □ Not sure what you mean. Have you been baptized? □ Yes / □ No If so, when? ______Where? ______If you were to die and stand before God and He asked you why He should permit you to enter Heaven, how might you respond? ______Have there been any spiritual changes or insights that have taken place in your life, if so, please explain ______2 ______

MEDICAL HISTORY Rate your health: □ Very Good □ Good □ Average □ Declining

What illnesses are you currently dealing with? ______

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What other illnesses have you had in the past and when did you have them? ______

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List any accidents where you were physically injured and when: ______

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List previous surgeries (those which required anesthesia): ______

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Date of last medical exam ______. Report ______

Physician’s name and address ______

Are you currently taking medication: □ Yes / □ No What? ______

How many hours of sleep do you average each night? ______Have there been any recent changes? □ Yes / □ No Is this sleep restful? □ Yes / □ No Have you or others noticed any changes in your personality (anger, mood swings, withdrawal) thinking and memory, or work habits? □ Yes / □ No If “yes,” please describe: ______Do you drink alcoholic beverages? □ Yes / □ No If yes how frequently and how much ______Have you ever used drugs for other than medical purposes? □ Yes / □ No If yes explain ______Have you ever had a severe emotional upset? □ Yes / □ No Explain: ______

Have you ever had any psychotherapy or counseling before? □ Yes / □ No If yes, list counselor or therapist, dates and what the purpose was: ______

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What was the outcome? ______

3 ______

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PROBLEM CHECK LIST (check all that apply) _____ Anger _____ Deception/lying _____ Guilt _____ Rebellion _____ Anxiety/worry _____ Decision Making _____ Homosexuality _____ Self-centeredness _____ Apathy _____ Depression _____ Hope _____ Sex _____ Appetite _____ Drunkenness _____ In-laws _____ Temptation _____ Bitterness/forgiveness _____ Envy _____ Loneliness _____ Trust _____ Change in lifestyle _____ Faith _____ Lust/porn _____ Other (list) _____ Children _____ Finances _____ Moodiness ______Communication _____ Gluttony _____ Perfectionism ______Conflict (fights) _____ Grief _____ Priorities ______

BRIEFLY ANSWER THE FOLLOWING QUESTIONS State in your own words the main problem that brings you to seek counseling: ______When did your problems begin? Please specify a date if possible. ______Please describe any significant events occurring at that time. ______What have you done to try to resolve your problem(s)? ______What do you believe God would want you to personally do regarding your problem(s)? ______What would you like us to try to do for you? What kind of help do you want from us? ______Is there any other information we should know?

4 ______