Kerans Christian Counseling: Personal Data Inventory

Kerans Counseling

Heart Change for Life Change
PERSONAL DATA INVENTORY FOR BIBLICAL COUNSELING (Confidential*)
Today's Date

MonthDayYear
Date
Name
Cell Phone
Home Phone
Address:
Email address
example@example.com
Place of employment
Work Phone
Sex
Birth Date

MonthDayYear
Date
Age
Married or Single?
Dating (Yes or No)
Separated (Yes or No)
Divorced (Yes or No)
Education (last year completed):
Degrees or certificates:
Other training:
Referred by:
HEALTH INFORMATION:
Rate Your Health: ( Examples: "Good," "Okay," "Poor," "Declining," or "Lost or Gained Weight")
List all important present or past illnesses or injuries or handicaps:
Date of last medical examination:

MonthDayYear
Date
Report:
Physician's name and address:
Are you presently taking medication? If yes, list. If no, leave blank.
list
Have you ever been arrested? (I want to make sure that any serious incidents in your past have been dealt with in a biblical manner)
Yes for "been arrested"
No for "been arrested"
When?
State circumstances and outcome:
If your counselor, Corinne Kerans believes that it would be helpful to see your social, psychiatric or medical reports, would you be willing to sign a release of information form? All information provided on this form will be kept confidential in the same manner as that disclosed during counseling sessions. *Please see the Confidentiality Policy.
"Yes or NO" for receiving reports
When considering your presenting problem, how would you describe your feelings? "Mildly upsetting" "moderately upsetting" "very upsetting" "extremely severe" or "totally incapacitating?"
RELIGIOUS BACKGROUND: (Raised Christian? Yes or no? if no, describe. Ex: "Jewish")
Church or religious center attended in childhood
Denominational preference now:
Current Church Membership:
Church attendance per month: 0 1 2 3 4 5 6 7 8 9 10+
Religious background of spouse (if married)
Do you believe in God? Write: Yes or No or Uncertain
Do you pray to God? Write: Never, Occasionally, or Often
Are you saved? Write: Yes, No, or Not sure what you mean.
Have you been baptized? Yes / No. If so, at what age?
How frequently do you read the Bible? (Never, Occasionally, or Often?)
Do you have regular family devotions? Yes or No. Also explain recent changes.
Explain any other recent changes in your religious life:
MARRIAGE AND FAMILY INFORMATION:
Name of spouse:
Address (if different)
Phone
Occupation
Business phone
Spouse's age
Education (in years)
Religion
Has your spouse been willing to do counseling? Yes/No
When?
Have you ever been separated? Yes/No and If so, when?
Has either of you ever filed for divorce? Yes/No and If so, when?
Date of marriage

MonthDayYear
Date
Write your ages when married (Ex: wife: 21, husband: 25)
How long did you know your spouse before marriage?
Length of dating with spouse:
Length of engagement:
Number of Children (if applicable) - please write first names and ages. (Ex: "Sarah, 6)
Give brief information about any previous marriages & include children:
If you were reared by anyone other than your parents, briefly explain:
How many older brothers or sisters do you have?
How many younger brothers or sisters do you have?
Have there been any deaths in the family? If so, who and when?
PERSONALITY INFORMATION:
Have you ever used drugs for other than medical purposes? Yes or No
What:
When:
Have you ever had a severe emotional upset? Yes/No and explain.
Have you ever had any psychotherapy or counseling before? If yes, list dates or just list the year if you can't remember.
What was the outcome?
When thinking about yourself: Write "yes" under any of the following words that best describe you NOW:
active
ambitious
persistent
nervous
hardworking
impulsive
moody
excitable
imaginative
calm
shy
introvert
extrovert
likable
leader
submissive
self conscious
lonely
sensitive
other
Have you ever had hallucinations? If yes, please describe and date.
Do you have problems sleeping? If yes, explain.
How many hours of sleep do you average each night?
PASTORAL INFORMATION:
Pastor's Name
Phone
Church Name
Address

Church Address

Street Address Line 2

CityState / Province

Zip
Permission to consult with pastor as deemed helpful by counselor, Corinne Kerans?
Yes or No to consult pastor?
PLEASE ANSWER THE FOLLOWING QUESTIONS
1. What is your problem? (What brings you here?)
2. What have you done about it?
3. What do you want Corinne to do? (What are your expectations in coming here?)
4. Is there any other information Corinne Should know?
Should be Empty:

Kerans Counseling

HEALTH INFORMATION:

MARRIAGE AND FAMILY INFORMATION:

PERSONALITY INFORMATION:

PASTORAL INFORMATION:

PLEASE ANSWER THE FOLLOWING QUESTIONS