Biblical Counseling Personal Data InventoryPlease complete the following inventory. Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth? * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Marital Status * Married Divorced Single Widowed Dating Sex * Male Female Occupation * Highest Level Education * High School/G.E.D. Associates Degree B.A./B.S. Post-Graduate Referred by: HEALTH INFORMATION Rate your health: * Very Good Good Average Declining List all important present or past illnesses, injuries or handicaps: Who is your primary physician? Are you currently taking any medication? * Yes No Please list any current medications: Have you used drugs recreationally? Yes No Which recreational drugs have you used? Have you ever been arrested? * Yes No Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports? * Yes No RELIGIOUS BACKGROUND What church do you attend? * Monthly Church attendance? * <1 1-2 2-3 3< Do you consider yourself a religious person? * Yes No I'm not sure Do you believe in God? * Yes No I'm not sure Do you pray to God? * Never Occasionally Often Are you saved? * Yes No Not sure How often do you read the Bible? * Never Occasionally Often Do you have regular family devotions? * Yes No Explain any recent changes in your religious life: COUNSELING INFORMATION Have you ever had any psychotherapy or counseling before? * Yes No If yes, list counselor or therapist and dates: What was the outcome? Which of the following words best describe you now? * Choose all that apply: Active Ambitious Self-Confident Persistent Nervous Hard-Working Impatient Impulsive Moody Excitable Imaginative Calm Serious Easy-Going Shy Good-Natured Introvert Extrovert Likable Quiet Submissive Self-Conscious Lonely Sensitive Which of the following describes your current experiences? * Please select all that apply Abuse Anger Anxiety Apathy Appetite Bitterness Change in Lifestyle Children Communication Conflict (fights) Deception Decision Making Depression Dunkenness Envy Fear Finacnes Gluttony Guilt Health Homosexuality Impotence In-Laws Loneliness Lust Memory Moodiness Perfectionism Rebellion Sexuality Sleep Other What is your problem (why are you pursuing counseling)? * What have you done about the problem? * What are your expectations from counseling? * Is there any other information that we should know? MARRIAGE & FAMILY INFORMATION Spouse's Name First Name Last Name Spouse's Address If different from yours. Address 1 Address 2 City State/Province Zip/Postal Code Country Spouse's Phone (###) ### #### Spouse's Date of Birth? MM DD YYYY Spouse's Occupation? Spouse's Religious Preference? Is your spouse willing to come for counseling? Yes No Uncertain Have you ever been separated? Yes No If separated, When? and How long? Have either of you ever filed for divorce? Yes No Wedding Anniversary? MM DD YYYY What were your ages when married? How long did you know your spouse before marriage? Please provide information regarding any previous marriages: Do you have any children? Please list name, age, sex, and wether the child in dependent/independent or from a previous marriage. Thank you! An elder from the church will follow up with you soon!
