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Personal Data Inventory
Before Counseling begins, the following information is needed
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Name:
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Address:
Your answer
Preferred Phone Number:
Your answer
Email Address:
Your answer
Gender:
Male
Female
Clear selection
Referred by:
Your answer
Education Level:
High School or less
Some College no Degree
Bachelor, Masters, PhD
Technical Degree (Welder, Stylist, etc)
Other:
Clear selection
Employer:
Your answer
Length of time at current (or last) employment:
Your answer
Current Situation:
Never Married
Married
Married but separated
Divorced
Widowed
Single
Living with someone
Clear selection
Do you have children?
Yes
No
Clear selection
Names and Ages of Children:
Your answer
Describe your health:
Your answer
List important illnesses, injuries, handicaps or chronic conditions:
Your answer
Have you ever been arrested?
Yes
No
Clear selection
If previous answer is yes, Why were you arrested?
Your answer
Are you a follower of Jesus Christ?
Yes
No
Clear selection
What church do you attend?
Your answer
How often do you attend church?
3 or more times per week
1 time per week
A couple of times a month
Only on special occasions
Other:
Clear selection
Do you feel like you are in Financial distress?
Yes
No
Maybe
Clear selection
Do you have significant debt?
Yes
No
Maybe
Clear selection
Problem check list - check as many as applicable
Anger
Anxiety
Apathy
Bitterness
Change in Lifestyle
Children
Communication
Conflict (Fights)
Deception
Decision Making
Depressions
Drunkenness
Eating Disorder
Envy
Family (specific persons - spouse, in-laws, etc
Fear
Finances
Homosexuality
Loneliness
Loss of Loved One
Lust
Memory
Moodiness
Perfectionism
Pornography
Rebellion
Sex (intrmaritial, extramarital, same sex, etc)
Sleep
Spousal Abuse
Other:
Please explain anything about your situation that you believe we need to know prior to your counseling session.
Your answer
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