Personal Data Inventory

Please complete this form carefully

You are ...

Women Only

Have you had any menstrual difficulties?

If you experience tension, tendency to cry, or other symptoms prior to your cycle, please explain:

Is your husband willing to come for counseling?

Is he in favor of you coming?

If no, please explain:

Other Training (List Type and years)


If you were raised by anyone other than your own parents, please explain:

Do you have siblings?


Are you married?

Length of dating:

Give a brief statement of circumstances of meeting and dating:

Have either of you been previously married?

Have you ever been separated?

Filed for divorce?

Children and Family

Please complete for each child


Describe relationship to your father:

Describe relationship to your mother:


Describe your health

Do you have any chronic conditions?

Please explain:


Current medication(s) and dosage:

Have you ever used drugs for anything other than medical purposes?

Please explain:

Have you ever been arrested?

Do you drink alcoholic beverages?

How frequently and how much?

Do you drink coffee and/or other caffeine drinks?

How frequently and how much?

Do you smoke?

What? Frequency?

Have you ever had interpersonal problems on the job?

Have you ever had a severe emotional upset?

Please explain:

Have you ever seen a psychiatrist or a counselor?

Please explain:



Do you believe in God?

Do you pray?

Would you say you are a Christian?

... or still in the process of becoming a Christian?

Have you been baptized?

Explain any recent changes in your religious life:

Problem checklist

Please indicate to what degree (on a scale of 0 to 3) the issues below affect you.

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?