Personal Data Inventory

To request counseling, please provide information in the form below. It will be kept confidential. Thank you,

General Information

Name *

Address

Sex

Email *

Occupation

Age

Phone *

Education

Marital Staus

Health Information

Your weight

Are you currently taking medication?

Recent Weight Changes?

Had a severe emotional upset?

Religious Background

Do you believe in God?

Church you attend?

Baptized?

Are you saved?

Are you a member?

Do you pray to God?

Denominational Preference?

Attend how often?

Have family devotions?

Personality and Social Information

Had psychotherapy or counseling before?

Afraid of being in a car?

Felt people were watching you

Problems sleeping?

Had hallucinations?

Ever been arrested?

Marriage and Family Information

Name of spouse

Age of husband when married?

Length of steady dating?

What is the main problem as you see it?

What do you want us to do about it?

Will your spouse come to counseling?

Age of wife when married?

Length of engagement

What have you done about it?

Is your spouse a Christian?

Marriage date?

You knew your spouse how long before marriage?

List any children with their age and gender

Agreement and Signature

Confidentiality and Disclosure ~ Confidentiality extends only as far as Mathew 18:18 allows. Sinful activity will be confronted according to those passages. Other counselors and pastors may be consulted on your case in general.

I understand this is Biblical, Christian counseling and I come willingly and of my own accord.

Signature

Thank you. Your form has been submitted and it will be kept private and confidential.

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