Personal Data Inventory
Please complete this form carefully
Name
Email
Phone
Work #
Street
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Birthdate
Occupation
Education
Choose one
Elementary
High School
GED
College
Graduate
Degree
Other Training (List Type and years)
Hobbies
If you were raised by anyone other than your own parents, please explain:
Do you have siblings?
No
Yes
Older brothers
Older sisters
Younger brothers
Younger sisters
You are ...
Male
Female
Women Only
Have you had any menstrual difficulties?
Yes
No
If you experience tension, tendency to cry, or other symptoms prior to your cycle, please explain:
Is your husband willing to come for counseling?
Yes
No
Is your husband in favor of you coming for counseling?
Yes
No
If no, please explain:
Marriage
Are you married?
No
Choose one
Single
Engaged
Divorced
Widowed
Yes
Date of Marriage
Spouse's Name
Spouse's Birth Date
Spouse's Occupation
How long employed?
Length of dating:
Years
Months
Give a brief statement of circumstances of meeting and dating:
Have either of you been previously married?
No
Yes
Please explain:
Have you ever been separated?
No
Yes
Please explain:
Filed for divorce?
No
Yes
Please explain:
Children and Family
How many children do you have?
None
1
2
3
4
5
6
7
8
9
Child 1
Age
Select
Biological
Step-child
Adopted
Living
Deceased
Child 2
Age
Select
Biological
Step-child
Adopted
Living
Deceased
Child 3
Age
Select
Biological
Step-child
Adopted
Living
Deceased
Child 4
Age
Select
Biological
Step-child
Adopted
Living
Deceased
Child 5
Age
Select
Biological
Step-child
Adopted
Living
Deceased
Child 6
Age
Select
Biological
Step-child
Adopted
Living
Deceased
Child 7
Age
Select
Biological
Step-child
Adopted
Living
Deceased
Child 8
Age
Select
Biological
Step-child
Adopted
Living
Deceased
Child 9
Age
Select
Biological
Step-child
Adopted
Living
Deceased
Describe relationship with your father:
Describe relationship with your mother:
Health
Describe your health
Do you have any chronic conditions?
No
Yes
Please explain:
Date of Last Medical Exam
Report:
Current medication(s) and dosage:
Have you ever used drugs for anything other than medical purposes?
No
Yes
Please explain:
Have you ever been arrested?
No
Yes
Do you drink alcoholic beverages?
No
Yes
How frequently and how much?
Do you drink coffee and/or other caffeine drinks?
No
Yes
How frequently and how much?
Do you smoke?
No
Yes
What? Frequency?
Have you ever had interpersonal problems on the job?
No
Yes
Have you ever had a severe emotional upset?
No
Yes
Please explain:
Have you ever seen a psychiatrist or a counselor?
No
Yes
Please explain:
Religious
Denominational Preference:
Church attending:
Member?
No
Yes
Church attendance per month:
Do you believe in God?
No
Yes
Do you pray?
No
Yes
Would you say you are a Christian?
No
Yes
... or still in the process of becoming a Christian?
Have you been baptized?
No
Yes
How often do you read your Bible?
Explain any recent changes in your religious life:
Problem checklist
Please indicate to what degree (0 to 3) the issues below affect you.
Anger
Anxiety
Apathy
Appetite
Bitterness
Change in Lifestyle
Children
Communication
Conflict (fights)
Deception
Decision-making
Depression
Drunkenness
Envy
Fear
Finances
Gluttony
Guilt
Health
Homosexuality
Impotence
In-laws
Loneliness
Lust
Memory
Moodiness
Perfectionism
Rebellion
Sex
Sleep
Wife abuse
A Vice:
Other:
Briefly Answer the Following Questions
What is your problem (what brings you here)?
What have you done about the problem?
What are your expectations from counseling?
Is there any other information that we should know?
Referred to us by:
Relationship:
Deliver to a particular counselor?