<p> CONFIDENTIAL PERSONAL DATA</p><p>Name:______</p><p>Gender:______</p><p>Age:______</p><p>Marital Status: single____ engaged____ married____ divorced____ separated____ widowed____</p><p>Occupation:______</p><p>______</p><p>Education (grade completed or degree):______</p><p>Special </p><p>Training:______</p><p>____</p><p>General Physical Health: excellent_____ good_____ fair_____ poor_____ </p><p>Recent weight change: #s gained_____ #s lost______none_____ </p><p>Describe any physical illness or accident:______</p><p>______</p><p>______</p><p>Date of last physical exam:______Examining </p><p>Physician:______</p><p>Results:______</p><p>______Address:______</p><p>______</p><p>List current medications and reasons taking them:______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>Have you ever used drugs recreationally? ______If yes, what kind:______</p><p>Do you currently? </p><p>______</p><p>Have you received prior counseling or psychotherapy? ______</p><p>Dates:______</p><p>Name of therapist/counselor:______</p><p>_</p><p>Reasons and results:______</p><p>______</p><p>______Are you willing to sign a release of information for present counselor to obtain psychiatric/psychological or medical reports? ______</p><p>Have you ever had an emotional upset? ______When? ______</p><p>Please explain:______</p><p>____</p><p>______</p><p>______</p><p>Have you recently experienced the loss of someone close to you? ______</p><p>If yes, explain:______</p><p>____</p><p>Have you recently experienced social, business or other loss? ______</p><p>If yes, explain:______</p><p>____</p><p>Circle any of the words below that would describe you:</p><p>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:______</p><p>RELIGIOUS INFORMATION</p><p>Church attended as a child:______Church spouse attended as a child:______</p><p>Church you attend now:______</p><p>Are you a member? Yes______No______</p><p>How often do you attend church now? ______times per week</p><p>Do you believe in God? Yes_____ No______Uncertain______</p><p>Are you saved? Yes_____ No______Uncertain______</p><p>Do you pray to God? Never______Occasionally ______Often ______Regularly ______</p><p>Do you read the Bible? Never______Occasionally ______Often ______Regularly ______</p><p>Do you have family devotions? Never______Occasionally ______Often ______Regularly </p><p>______</p><p>Have you had any recent changes in your spiritual life? ______</p><p>If yes, explain: </p><p>______</p><p>FAMILY INFORMATION</p><p>Were you raised by anyone other than your parents? Yes______No______</p><p>If yes, please explain the circumstances: </p><p>______</p><p>______</p><p>______Number of older brothers:______sisters:______</p><p>Number of younger brothers: ______sisters:______</p><p>Spouse’s Name: ______Spouse’s </p><p>Age:______</p><p>Spouse’s Education (grade completed or degree): </p><p>______</p><p>Spouse’s Occupation: </p><p>______</p><p>Have you ever been separated? Yes______No______</p><p>If yes, why?</p><p>______</p><p>Date Married:______</p><p>Ages when married: You:______Spouse:______</p><p>Was this your first marriage? Yes_____ No____ </p><p>If not, explain what happened in previous marriage(s):______</p><p>______</p><p>______</p><p>______</p><p>How long did you know present spouse before marriage? ______</p><p>Length of engagement: ______</p><p>Names, ages and gender of children (indicate if any are by other marriages) NAME AGE GENDER PRESENT OR PREVIOUS MARRIAGE LIST </p><p>ANY ISSUES</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>Describe the Problems you are seeking help with:</p><p>What steps have you taken to solve it?</p>