CHRISTIAN COUNSELING & EDUCATIONAL SERVICES

PERSONAL DATA INVENTORY

Name
Address
City
State
Zip code
Home phone
Cell phone

Work phone
Email address


Date of birth
Age
Male
 Female

Last year of school completed:
 High School: 9 10 11 12 GED
College: 1 2 3 4 Graduate School

Place of employment:
How long?
Position:



EARLY FAMILY HISTORY
If you were reared by someone other than your biological parents, please explain:

Number of older brothers:

Number of older sisters:

Number of younger brothers:

Number of younger sisters:

In your childhood home, did you live with anyone who was:
an alcoholic a drug user
physically abusive mentally ill

 

MARITAL INFORMATION

 
Single, never married Living together without marriage
Engaged  
How long?

Married
How long?

Widow/er
How long?

Separated
How long?

Divorced
How long?

Spouse's name:
Spouse's age:
Spouse's occupation:
Spouse's address (if not the same as yours):
Spouse's place of employment and phone:

Education of spouse:		  
Elementary High School
College Graduate School

Is your spouse willing to come for counseling?		 Yes     No

Ages when married:
Husband Wife
Length of dating:

Please provide information about previous marriages:

 

CHILDREN

 
Please list your children's names, ages, sex, and relationship to you (please note if children are from a previous marriage):

Are your children living at home?

 

COUNSELING HISTORY
Have you ever been to counseling for any reason?
Yes    No
What reason?
How long?
Counselor:

Have you ever had a severe emotional upset?
Yes    No
If yes, please explain

Are you presently working with any other counselor or psychologist?
Yes    No
What reason?
How long?
Counselor:

Are you involved in any other marriage counseling, family counseling, or support groups?
Yes   No
Please specify:


Briefly state the problem as you see it:


What have you done to try and resolve these matters?

What do you want to gain from counseling?

Who referred you to this counseling office?

Is there any other information we should have?

 

RELIGIOUS BACKGROUND

 
What church do you attend, if any?

What is your pastor's name and phone number?

How strong is the influence of your church in your life?
Very important   Somewhat   None

Religious/church background of your spouse:

Have you come to a place in your spiritual life where you can say that you know for certain that if you were to die today you would go to heaven?
Yes    No

Have you had any recent changes in your spiritual life?
Yes    No
If yes, please explain:

Select the following words which best describe your normal self (check all that apply):

Active    Fearful    Nervous    Sensitive

Affectionate    Frightened    Overwhelmed    Serious

Aggressive    Good-natured    Outgoing    Shy

Angry    Helpful    Patient    Spontaneous

Anxious    Hopeless    Peaceable    Steady

Bossy    Hurt    Practical    Stubborn

Calm    Impatient    Quarrelsome    Talkative

Confused    Impulsive    Quiet    Trapped

Depressed   Lazy    Reliable    Trusting

Distrustful    Logical    Sad    Withdrawn

Easy going    Lonely    Sarcastic    Worrying

Emotional    Moody    Self-controlled


List any fears that you have:

 

MEDICAL INFORMATION

 
Family Physician:
Psychiatrist/Psychologist:

Are you taking prescription drugs?
Yes    No

If yes, state the drug name(s)/purpose:

Describe your physical health:
Excellent    Good    Adequate    Poor

Have you ever been hospitalized for mental illness or substance abuse?
Yes    No

If yes, for what reason?

How long were you in treatment?

What hospital?

How long ago?

Did you continue with outpatient counseling?
Yes    No

Name of counselor:

Drugs used other than for medical purposes:

When was the last time for use?

Weight changes recently:
Lost    Gained

Have you had any of the following physical problems in the past 2 years? (check all that apply)
AIDS Diabetes
Allergies Menstrual Irregularities
Headaches Personality Changes
Heart Problems Anorexia/Bulemia
Seizures HIV Positive
Blackouts Sleep Disturbances
Brain Tumor Thyroid Problems
Impotence Chronic Fatigue Syndrome
Memory Problems

List any surgeries, major illnesses or physical disabilities and dates:

 

IMPACT OF LIFE CIRCUMSTANCES

 

Check any LOSSES that you have experienced in the last 2 years:
Death of:
Spouse Child
Father Mother
Sister Brother
Grandmother Grandfather
Friend

Divorce
Separation
Broken engagement Suicide
Miscarriage Abortion
Infertility Bankruptcy
Homelessness Job/career loss
Other If other, please specify

 

Check any VICTIMIZATIONS you have experienced or been involved with:
Child abuse:
Physical Emotional
Sexual Incest

Spouse abuse:
Physical Emotional
Sexual Verbal

Abandonment
Rape
Robbery Assault
Suicide Attempt Auto or Industrial Accident
Alienation Other
If other, please specify:

 

Check any PROBLEMS that concern you now:

Relationship(s) with:
Spouse Children
Parents In-laws
Friends Co-workers
Teachers

Alcohol
Prescription drugs
Street drugs Work too much
Shopping Binge eating
Procrastination Excessive dieting or exercise
Communication Depression
Anger Grief
Sex Homosexuality
Sexual addiction Career
Loneliness Mood swings
Self-esteem Codependency
Stress Fear
Anxiety Feelings about church or God
Other If other, please specify

 

INTENSE EMOTIONAL DISTRESS

 

If any of these situations currently apply to you, please explain:

Suicidal thoughts, plans, attempts:

Homicidal thoughts, plans, attempts:

Desire to cause pain to self or others:

In fear for your life or personal safety:

Too depressed to care for self or family:


I affirm that the information given on this form is true and complete

 

If this form has been completed for a minor, please give your name and relationship: