Education (Grade Completed Or Degree):______

CONFIDENTIAL PERSONAL DATA

Name:______

Gender:______

Age:______

Marital Status: single____ engaged____ married____ divorced____ separated____ widowed____

Occupation:______

______

Education (grade completed or degree):______

Special

Training:______

General Physical Health: excellent_____ good_____ fair_____ poor_____

Recent weight change: #s gained_____ #s lost______none_____

Describe any physical illness or accident:______

______

Date of last physical exam:______Examining

Physician:______

Results:______

______Address:______

______

List current medications and reasons taking them:______

______

Have you ever used drugs recreationally? ______If yes, what kind:______

Do you currently?

______

Have you received prior counseling or psychotherapy? ______

Dates:______

Name of therapist/counselor:______

Reasons and results:______

______

______Are you willing to sign a release of information for present counselor to obtain psychiatric/psychological or medical reports? ______

Have you ever had an emotional upset? ______When? ______

Please explain:______

______

Have you recently experienced the loss of someone close to you? ______

If yes, explain:______

Have you recently experienced social, business or other loss? ______

If yes, explain:______

Circle any of the words below that would describe you:

ACTIVE SELF-CONFIDENT NERVOUS AMBITIOUS WORRIED HARDWORKING IMPULSIVE LIKEABLE IMPATIENT MOODY ATTRACTIVE CALM SEROUS LONELY SENSTIVIE SHY SUBMISSIVE CAPABLE INTROVERTED SHORT-TEMPERED EXCITABLE GOOD- NATURED QUIET EXTROVERTED AFFECTIONATE TIRED SELF-CONSCIOUS LEADER FRIENDLY BLUE ENERGETIC DISTRACTED HARD-BOILED HOPEFUL ANNOYED DAYDREAMER FRUSTRATED REJECTED FEARFUL GUILTY DEPRESSED USELESS SUICIDAL DESPERATE OTHER:______

RELIGIOUS INFORMATION

Church attended as a child:______Church spouse attended as a child:______

Church you attend now:______

Are you a member? Yes______No______

How often do you attend church now? ______times per week

Do you believe in God? Yes_____ No______Uncertain______

Are you saved? Yes_____ No______Uncertain______

Do you pray to God? Never______Occasionally ______Often ______Regularly ______

Do you read the Bible? Never______Occasionally ______Often ______Regularly ______

Do you have family devotions? Never______Occasionally ______Often ______Regularly

______

Have you had any recent changes in your spiritual life? ______

If yes, explain:

______

FAMILY INFORMATION

Were you raised by anyone other than your parents? Yes______No______

If yes, please explain the circumstances:

______

______Number of older brothers:______sisters:______

Number of younger brothers: ______sisters:______

Spouse’s Name: ______Spouse’s

Age:______

Spouse’s Education (grade completed or degree):

______

Spouse’s Occupation:

______

Have you ever been separated? Yes______No______

If yes, why?

______

Date Married:______

Ages when married: You:______Spouse:______

Was this your first marriage? Yes_____ No____

If not, explain what happened in previous marriage(s):______

______

How long did you know present spouse before marriage? ______

Length of engagement: ______

Names, ages and gender of children (indicate if any are by other marriages) NAME AGE GENDER PRESENT OR PREVIOUS MARRIAGE LIST

ANY ISSUES

______

Describe the Problems you are seeking help with:

What steps have you taken to solve it?