Members Counseling & Care: PDI Form
Email address *
First Name *
Your answer
Last Name *
Your answer
Address Information
Street Address
Street Address & Address Line 2
Your answer
City
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State / Province / Region
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Postal / Zip Code
Your answer
Country
Your answer
Phone Number
Your answer
Age
Your answer
Date of Birth
MM
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DD
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YYYY
Sex
Your answer
For confidentiality, when/where do you prefer to be reached?
Your answer
Emergency Contact Name / Relationship
Your answer
Emergency Contact Phone
Your answer
How long have you been a member at Third Avenue?
Your answer
Whose Home Group do you currently attend?
Your answer
Have you informed your Home Group leader that you're in need of assistance?
Your answer
Family Information
Marital Status
Wedding Date of Current Marriage
MM
/
DD
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YYYY
How many times have you been married?
Your answer
Spouse's Name (If Married)
Your answer
Spouse's Date of Birth
MM
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DD
/
YYYY
Have you ever been separated? If so, when and how long?
Your answer
Have either of you filed for divorce? If so, when?
Your answer
Number of children / ages?
Your answer
Any other information about your family that would be helpful to know?
Your answer
Scheduling Information
What times/days are you generally available?
Your answer
Is there any other information about scheduling that would be helpful to know?
Your answer
Health / Medical Information
Rate your heath
Have you experienced any significant weight changes in the past year?
Your answer
List any MAJOR present or past illnesses, injuries, or physical complications
Your answer
List medications you are presently taking and their purpose
Your answer
Date of last medical examination
MM
/
DD
/
YYYY
Your Physician
Your answer
Have you been hospitalized recently? Reason for hospitalization?
Your answer
Have you sought psychotherapy or counseling before?
If yes, list the counselor/therapist and time period
Your answer
Were you satisfied with the results from previous counseling?
Your answer
If applicable, is your spouse willing to come in for counseling?
Your answer
Occupational / Educational Information
What is your occupation?
Your answer
What is your level of education?
Your answer
If currently a student, are you full time or part time? What is your field of study?
Your answer
Religious Information
Do you consider yourself to be a Christian?
If yes, please describe how your relationship with Christ began, how it has progressed, and if there has been any recent change in your religious life.
Your answer
Personality Information
Have you ever experienced a severe emotional upset that negatively affected your daily functioning? If yes, explain.
Your answer
List your addictions
Your answer
Have you ever had hallucinations?
Your answer
How many hours of sleep do you get per night?
Your answer
Do you ever feel suicidal? If so, explain.
Your answer
Please check how often the following thoughts occur to you
Life is hopeless
I am lonely
No one cares about me
I am a failure
Most people don't like me
I want to die
I want to hurt someone
I am stupid
I am going crazy
I can't concentrate
I am depressed
God is disappointed in me
I can't be forgiven
Why am I so different?
I can't do anything right
People hear my thoughts
I have emotional numbness
Someone is watching me
I hear voices in my head
I am out of control
Please comment on the above thoughts that occur frequently, or thoughts that are especially of concern to you.
Your answer
Briefly answer the following questions:
What is the main problem(s) you would like to address? *
Your answer
What areas of life are being affected by this problem?
How long has this problem existed?
Your answer
How have you attempted to resolve this issue prior to seeking help?
Your answer
How might things be different for you if this issue was remedied?
Your answer
What I desire more than anything in life is:
Your answer
What I fear most in life is:
Your answer
What results/expectations do you hope to receive from this process? *
Your answer
Is there any other information that we should know?
Your answer
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