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Personal Data Inventory
Please enable JavaScript in your browser to complete this form.
First Name
Last Name
Email
Gender
Male
Female
Other
Age
Are you married?
Yes
No
Name of spouse?
Is your spouse willing to come to counseling?
Yes
No
Is your spouse in favor of you coming to counseling?
Yes
No
Please explain:
Briefly describe the circumstances of meeting and datiing
How long did you date before marriage?
What is your spouse's age?
Occupation of spouse
Length of employment
Has your spouse been previously married?
Yes
No
What were the circumstances of the divorce?
Have you been divorced?
Yes
No
What were the circumstances of your divorce?
Have you and your current spouse ever been separated or filed for divorce?
Yes
No
Please explain:
Do you have any children?
Yes
No
Please provide the name(s) and age(s) of children
Rate your overall physical health
Very Good
Good
Average
Declining
Other
List all important present or past illnesses or injuries or handicaps:
Are you presently taking any medication?
Yes
No
What medications are you currently taking?
How many hours of sleep do you average each night? Has there been any recent changes?
Do you drink alcoholic beverages?
Yes
No
How frequently do you drink and how much?
Do you drink caffeinated drinks?
Yes
No
What and how much caffeine?
Do you smoke?
Yes
No
What do you smoke and how often?
Have you ever used drugs for other than medical purposes?
Yes
No
Please explain:
Rate your overall mental health:
Very Good
Good
Average
Declining
Other
Have you ever had a severe emotional upset?
Yes
No
Please explain:
Have you been to counseling or therapy in the past?
Yes
No
What was the outcome?
Have you ever been hospitalized for mental illness?
Yes
No
Please explain:
What is your highest level of education:
High School
Some College
Associates Degree
College Degree
Masters Degree
Ph.D
What is your current occupation?
Who is your employer?
How long have you been employed there?
What jobs have you held in the past?
Does your present work satisfy you?
Yes
No
Please explain:
Have you had any interpersonal problems on the job?
Yes
No
Please explain:
Present annual income
During childhood or adolescence, did you experience any of the following problems:
School problems
Family problems
Medical problems
Drug/alcohol problems
Social problems
Legal problems
Please explain:
Describe your relationship with your father
Describe your relationship with your mother
Were you raised by anyone other than your birth parents?
Yes
No
Please explain
Did you experience any traumatic events growing up?
Yes
No
Please explain
Have you ever been arrested?
Yes
No
Please explain:
What is your denominational preference?
What church do you attend?
Are you a member?
Yes
No
How often do you attend church monthly?
0
1
2
3
4
5
6
7
8+
Do you believe in God?
Yes
No
Do you pray?
Yes
No
Would you say you are a Christian?
Yes
No
In the process of becoming a Christian
Not sure
Have you been baptized?
Yes
No
How old were you?
How often do you read the Bible?
Never
Occasionally
Often
Daily
Explain any significant changes in your spiritual life:
Please check any problems you experience:
Anger
Anxiety (worry)
Apathy (don't care)
Bitterness
Change in lifestyle
Children
Communication
Conflict (fights)
Deception
Decision-making
Depression
Drunkenness
Envy
Fear
Finances
Gender Identity
Gluttony
Guilt
Health
Homosexuality
Impotence
In-laws
Loneliness
Lust
Memory
Moodiness
Perfectionism
Pleasing Others
Rebellion
Sex
Sleep
Spousal Abuse
A Vice
Other
Have you recently suffered the loss of someone close to you?
Yes
No
Please explain:
What is your reason for seeking counseling? (Describe the problem)
*
What have you done to try and fix the problem?
What are your greatest fears and worries concerning the problem?
What do you believe is the best possible outcome concerning the problem?
What else should we know about the problem?
Comment
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