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Personal Data Inventory

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Today's Date

Name

Email

Phone

Address

Sate

Zip

Birthdate

Age

Occupation

Employer

Gender

Education

Other Training

Hobbies

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Emergency Contact

Emergency Contact Name

Emergency Contact Phone

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Referral

Referred By

Relationship

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Marital Information

Who shares your household

Marital Status

Name of Spouse

Spouse Address

Spouse Phone

Spouse Occupation

Spouse Religion

Spouse Eduction

Does your spouse know you are comming to counseling?

Please provide information about previous marriages if applicable:

Please list the names and ages of any children:

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History

If raised by someone other than your own parents, briefly explain:

How many siblings do you have and where are you in order of birth::

Was there anything unusual in your childhood or adolescent years:

If yes, briefly describe:

Have you dealt with severe emotional struggles, abuse, or trauma in the past:

If yes, briefly describe:

Have you ever wanted to harm yourself of others:

If yes, briefly explain:

Have you ever participated in counseling or therapy in the past:

Please list counselor/therapist and dates:

What was the result of your counseling:

List any fears you have:

Have you ever been arrested:

Please explain the reason for your arrest:

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Health Information

Rate your health:

Last physical:

Are you taking prescription drugs?

If you are taking prescription drugs, please list them:

How often do you consume alcohol:

In the past 5 years, have you taken illegal drugs or abused prescriptions drugs:

Approximately how much sleep to you get each night:

When do you usually go to sleep and get up:

Have you recently lost or gained a significant amount of weight:

Do you have any chronic medical conditions:

If you have chronic medical conditions, please list them:

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Religious Background

What church (if any) did you attend in childhood:

How long have you attended MBC:

Do you believe in God:

How often do you pray to God:

How often do you read the Bible:

Do you know for certain if you were to die today, you would go to heaven:

What would you say if you died today and God asked you why should you be allowed in heaven:

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Other

Are you involved in any legal action at this time:

If you are involved in any legal action, please explain:

How would you describe the issues which brought you here:

How have you tried to deal with them:

What are your expectations and goals in coming to counseling at VBVF:

What prompted you to come at this time:

Is there any other information you would like to share or think we should know:

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By checking, I acknowledge that I have read and agree with the Biblical Counseling Services Principles and Procedures. Click here to read: Biblical Counseling Services Principles and Procedures.

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