Personal Data Inventory
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Today's Date
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Name
*
Address
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Best phone # to reach you
*
Email
Occupation
Sex
Please select one option.
Male
Female
Select Option
Male
Female
Birthdate
Age
Height
Marital Status
Please select one option.
Single
Dating
Married
Separated
Divorced
Widowed
Select Option
Single
Dating
Married
Separated
Divorced
Widowed
Education (last year completed)
Other training (list type and years)
Referred here by:
Health Information
Rate your health
Please select one option.
Very Good
Good
Average
Declining
Other
Select Option
Very Good
Good
Average
Declining
Other
Your approximate weight
Weight changes recently (lost or gained?)
Please list all important present or past illnesses, injuries or handicaps
Please tell us the date of your last medical examination. Doctor's report?
Physician's Name
Physician's Address
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KY
LA
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MI
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MO
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NJ
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ON
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PA
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RI
SC
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TN
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VA
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WA
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WY
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Are you presently taking medication? If so, what?
Have you used drugs other than for medical purposes? If so, what?
Have you ever had a severe emotional upset? Explain.
Have you ever been arrested? If so, please explain.
Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports?
Please select one option.
Yes
No
Select Option
Yes
No
Religous Background
Denominational preference
Are you a member of any congregation?
Church attendance per month
Please select one option.
None
1-2 times
3-4 times
More than 5 times
Select Option
None
1-2 times
3-4 times
More than 5 times
Church attended in childhood
Religious background of spouse (if married)
Do you consider yourself a religious person?
Please select one option.
Yes
No
I'm not sure
Select Option
Yes
No
I'm not sure
Do you believe in God?
Please select one option.
Yes
No
I'm not sure
Select Option
Yes
No
I'm not sure
Do you pray to God?
Please select one option.
Often
Occasionally
Never
Select Option
Often
Occasionally
Never
Are you saved?
Please select one option.
Yes
No
Not sure what you mean
Select Option
Yes
No
Not sure what you mean
How much do you read the Bible?
Please select one option.
Often
Occasionally
Never
Select Option
Often
Occasionally
Never
Do you have regular family devotions?
Please select one option.
Yes
No
Select Option
Yes
No
Explain recent changes in your religous life, if any:
Personality Information
Have you ever had any psychotherapy or counseling before?
Please select one option.
Yes
No
Select Option
Yes
No
If yes, list counselor or therapist, and dates:
What was the outcome?
Check any of the following words which best describe you:
Please select all that apply.
Active
Ambitious
Self-confident
Persistent
Nervous
Hardworking
Impatient
Impulsive
Moody
Often blue
Excitable
Imaginative
Calm
Serious
Easy going
Shy
Good natured
Introvert
Extrovert
Likable
Leader
Quiet
Hard-boiled
Submissive
Self-conscious
Lonely
Sensitive
Have you ever experienced debilitating anxiety?
Please select one option.
Yes
No
Select Option
Yes
No
Do you have any unsual fears?
Please select one option.
Yes
No
Select Option
Yes
No
Have you ever self-mutilated (ex: cutting yourself)?
Please select one option.
Yes
No
Select Option
Yes
No
Have you ever experienced hallucinations?
Please select one option.
Yes
No
Select Option
Yes
No
Have you ever thought of/or attempted suicide?
Please select one option.
Yes
No
Select Option
Yes
No
Have you ever experienced eating problems?
Please select one option.
Yes
No
Select Option
Yes
No
Do you have problems sleeping?
Please select one option.
Yes
No
Select Option
Yes
No
Marriage & Family Information
Name of Spouse
Address
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AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Phone
Spouse's occupation
Spouse's age
Spouse's Education
Spouse's religion (if any)
Is your spouse willing to come for counseling?
Please select one option.
Yes
No
Not sure
Select Option
Yes
No
Not sure
Have you ever been separated? If so, when?
Has either of you ever filed for divorce? If so, when?
Date of Marriage
Please list your ages when you married.
How long did you know your spouse before marriage?
Length of engagement?
Give brief information about any previous marriages.
Information about children. Please list their name, age, sex, if they are still living, education, and marital status. Please note with an * if the child is from a previous marriage.
If you were raised by anyone other than your own parents, briefly explain:
How many older siblings do you have?
How many younger siblings do you have?
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