PERSONAL DATA INVENTORY
THIS PERSONAL DATA INVENTORY WILL COLLECT THE INFORMATION NEEDED PRIOR TO THE COUNSELING EXPERIENCE. THIS DATA WILL HELP THE COUNSELOR TO BETTER SERVE THE COUNSELEE. ALL THE INFORMATION IN THIS QUESTIONNAIRE IS SECURE AND COMPLETELY CONFIDENTIAL.
NAME *
CONTACT INFORMATION: CELL # AND EMAIL ADDRESS *
GENDER *
MARITAL STATUS *
REFERRED BY *
RATE YOUR CURRENT PHYSICAL HEALTH *
HAVE YOU EVER HAD A SEVERE EMOTIONAL UPSET? *
HAVE YOU EVER HAD A PROBLEM WITH ALCOHOL OR DRUG ABUSE (PRESCRIPTION OR NON PRESCRIPTION) *
HAVE YOU EVER BEEN PHYSICALLY ABUSED AS A CHILD OR AS AN ADULT? *
HAVE YOU EVER BEEN SEXUALLY MOLESTED, EITHER AS A CHILD OR AS AN ADULT? *
HAVE YOU SEEN A PSYCHOLOGIST, PSYCHIATRIST OR/AND COUNSELOR? *
IF YES, TO THE PREVIOUS QUESTION, LIST COUNSELORS AND DATES. *
ARE YOU WILLING TO SIGN A RELEASE OF INFORMATION FORM SO THAT YOUR COUNSELOR MAY WRITE FOR HELPFUL SOCIAL, PSYCHIATRIC, OR MEDICAL REPORT? *
HAVE YOU EVER BEEN ARRESTED? *
IF YES TO THE PREVIOUS QUESTION, FOR WHAT REASON? *
ARE YOU PRESENTLY TAKING ANY MEDICATION? *
IF YES TO THE PREVIOUS QUESTION, PLEASE IDENTIFY MEDICATIONS. *
CURRENT CHURCH YOU ATTEND (IF ANY) *
ARE YOU A MEMBER OF A CHURCH? *
CHURCH ATTENDANCE PER MONTH *
ARE YOU SAVED? *
HOW OFTEN DO YOU READ THE BIBLE? *
HOW WOULD YOU DESCRIBE YOUR PERSONAL RELATIONSHIP WITH JESUS CHRIST? *
NAME OF SPOUSE (IF MARRIED) *
IS YOUR SPOUSE WILLING TO COME IN FOR COUNSELING? *
IF YOU HAVE CHILDREN, HOW MANY? *
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