Personal Data Inventory - Heart Talk Biblical Counseling

First Name

Last Name

Email

Phone

Gender

Age

Address

Address Line 1

City

State

Zip Code

Are you married?

Yes
No

Is your spouse willing to come to counseling?

Yes
No

Is your spouse in favor of you coming to counseling?

Yes
No

Have you been divorced?

Yes
No

Have you and your current spouse ever been separated or filed for divorce?

Yes
No

Do you have any children?

Yes
No

List all important present or past illnesses or injuries or handicaps:

Are you presently taking any medication?

Yes
No

How many hours of sleep do you average each night? Has there been any recent changes?

Do you drink alcoholic beverages?

Yes
No

Do you drink caffeinated drinks?

Yes
No

Do you smoke?

Yes
No

Have you ever used drugs for other than medical purposes?

Yes
No

Have you ever had a severe emotional upset?

Yes
No

Have you been to counseling or therapy in the past?

Yes
No

Have you ever been hospitalized for mental illness?

Yes
No

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

Have you had any interpersonal problems on the job?

Yes
No

Present annual income

Describe your relationship with your father

Describe your relationship with your mother

Were you raised by anyone other than your birth parents?

Yes
No

Did you experience any traumatic events growing up?

Yes
No

Have you ever been arrested?

Yes
No

What is your denominational preference?

What church do you attend?

Are you a member?

Yes
No

How often do you attend church monthly?

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 often do you read the Bible?

Explain any significant changes in your spiritual life:

Have you recently suffered the loss of someone close to you?

Yes
No

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?