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Personal Data Inventory
Please enable JavaScript in your browser to complete this form.
Personal Information
-
Step
1
of 8
First Name
Last Name
Email
Phone
Gender
Male
Female
Other
Age
Address
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Next
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
Date of marriage
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
How long did you date before marriage?
What is your spouse's age?
Occupation of spouse
Length of employment
Spouse's phone number
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
Next
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:
Next
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:
Next
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
Next
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:
Next
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:
Next
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?
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