Personal Background Form
This inventory gives us an overview of your story so we can understand how best to serve you. Please fill it out honestly and thoughtfully. We will handle the information with loving prudence.
Email address *
GENERAL INFORMATION
We’ll need your basic information to contact you and get a general sense of what occupies your life.
Full Name *
Your answer
Full Address *
Your answer
Cell Phone
Your answer
Home Phone
Your answer
Work Phone
Your answer
Email
Your answer
Date of Birth *
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Age *
Your answer
Sex *
Employed? *
Employer and Current Position
Your answer
Duration with Current Employer
Your answer
Education *
Your answer
Do you attend Harvest Bible Chapel Brantford? *
If so, how long have you attended HBC Brantford?
Your answer
If not, what church do you attend and how long?
Your answer
Have you attended Harvest Welcome? *
Have you completed Harvest Essentials? *
Are you in a small group? *
If yes, who are your small group leaders?
Your answer
Are you serving Harvest? *
If yes, which ministry do you serve in?
Marital Status *
MARRIAGE AND FAMILY
Few relationships are as involved in your daily experience as family. We’ll need the basics to understand how best to help you. If there is anything you think we should know that isn’t mentioned in this section, please feel free to write it in.
Spouse/significant other:
Your answer
Spouse birthdate:
MM
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DD
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YYYY
Spouse occupation:
Your answer
For how long?
Your answer
Date of marriage:
MM
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DD
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YYYY
Length of dating:
Your answer
Give a brief statement of circumstances of relationship... I.E. meeting, dating etc
Your answer
Have you ever been separated from one another?
Have you ever filed for a divorce?
Have either of you been previously married?
To whom?
Your answer
Do you have any children? *
What are your kids names and ages?
Your answer
Any additional information you think we should know: *
Your answer
GROWING UP YEARS
While we don’t think that childhood experiences strictly determine how we respond as adults, we do recognize that past experience influences present perspectives. So we will ask you to describe the family you came from. Again, if there is anything you think we should know that isn’t mentioned in this section, please feel free to write it in
Describe your relationship with your father: *
Your answer
Describe your relationship with your mother: *
Your answer
Did you live with anyone other than your parents? *
If so, please describe the relationship.
Your answer
Describe your relationship with your siblings: *
Your answer
Describe any significant events in your family life growing up: *
Your answer
Any additional information you think we should know: *
Your answer
HEALTH
We are physical as well as spiritual beings, and our bodies are an important factor in our experience. Though we are not medical professionals, it’s helpful for us to know general facts about your health.
Describe your health generally: *
Your answer
Do you have any chronic conditions or significant illness, injury or handicaps? *
If yes, please describe:
Your answer
PROFESSIONAL MEDICAL HELP
Physicians name and address: *
Your answer
Date of last medical exam: *
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DD
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YYYY
Have you ever seen a psychiatrist/ psychologist? *
If yes, please explain:
Your answer
Psychiatrist/Psychologist's name and address:
Your answer
Date of last appointment:
MM
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DD
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YYYY
Are you willing to sign a release of information form so that your counsellor may attain social, psychiatric, or other medical records? *
List all current medications: *
Your answer
Have you ever used drugs for anything other than medical purposes? *
Do you drink alcohol? *
Do you drink caffeine? *
Do you use tobacco products? *
Have you ever been arrested? *
If yes, please explain:
Your answer
Have you ever had interpersonal problems at work? *
If yes, please explain:
Your answer
Have you ever had a severe emotional upset? *
If yes, please explain:
Your answer
WOMEN ONLY:
Please explain any menstrual symptoms that affect your functioning, I.E. tension, tendency to cry etc:
Your answer
If married, is your husband supportive of your coming for counseling?
Is he willing to be involved?
Do you feel safe at home? *
CHILDREN ONLY:
How open are you with your parents/caretakers about your troubles? *
Your answer
Do you feel safe at home? *
SPIRITUAL PURSUIT
While we view all of human life as spiritual in nature, our religious identification indicates a lot about how we exercise our spirituality. We ask this information to get a better grasp of how you pursue God in your life experience.
Weekly church service attendance: *
What denominations or religions have you been involved with in the past? Please note any significant changes in your religious life. *
Your answer
Which statement best describes your relationship to Jesus Christ? If you don’t like any of these, write your own. *
If you pray, describe your prayer life. *
Your answer
How often do you read the Bible? *
Does God have anything to do with the problem that troubles you? *
If yes, please explain:
Your answer
PROBLEM CHECKLIST
We realize that problems can’t be described fully in a form like this. Your responses will more effectively help us care for you. If the problem is not listed here, feel free to write it in.
Check all that apply: *
Required
PROBLEM OVERVIEW in Your Own Words:
Describe what problem brings you here. *
Your answer
What have you done about the problem so far? *
Your answer
What are your expectations from counseling? *
Your answer
Is there any other information that we should know? *
Your answer
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