The Damascus House PDI

Are you a male or a female? IF YOU ARE A FEMALE THIS IS THE WRONG FORM. Please go back out to the main website and click on the "women's" tab.*

FEMALEMALE
Personal Data Inventory

Please fill out every field and ensure you sign all the proper fields
Name*

First NameMiddle NameLast Name
Cell Phone Number*
Please enter a valid phone number.
Can we text your cell phone number?*

YESNO
Email*
example@example.com
Home Phone Number (if applicable)
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation*
Business Phone (if applicable)
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Age*
Sex*
Marital Status*
Do you have children?*

YesNo
Education (last year completed): *
Other training (list the type and years completed):*
Referred to Canyon Hills Community Church by:*
Email of Referal
example@example.com
Phone Number of Referral *
Please enter a valid phone number.
HEALTH INFORMATION
Rate your health:

Very GoodGoodAverageDecliningOther
Weight Changes:

LostGainedNeither
List all important present or past, illnesses, injuries or handicaps*
Date of last medical examination:*
Medical examination report: *
Do you take any medications?*

YESNO
Explain*
Do you have any food allergies?*
Do you use alcohol or drugs?*

YESNO
Which of the following substances have you experimented with, past or current?*

AlcoholCrankCrystal MethMarijuanaSpiceHallucinogenic (Acid, LDS, ect)Amphetamines (Uppers)Barbiturates (Downers)Meth AmphetaminesMorphineOpiatesHeroinCocaineInhalantsCrackTabaccoEcstacyFentanylOther

Preferred Drugs:*

	Name of Drug	Frequency of Use	Date of Last Use
Drug Name
Drug Name
Drug Name
Drug Name

Have you ever been arrested?*

YESNO
Explain*
Have you ever taken drugs other than for medical purposes?*

YESNO
Explain*
Have you had a severe emotional upset?*

YESNO
Explain*
Have you recently suffered the loss of someone close to you?*

YESNO
Explain*
Have you recently suffered the loss from a serious social, business or other reversals?*

YESNO
Explain*
CHURCH BACKGROUND
Are you a Canyon Hills*

MemberAttenderVisitorNone
How often do you attend church per month?*

NeverRarely (once a month)Often (2-3 a month)Regularly (4 a month)
Have you been baptized?*

YESNO
Church attended in childhood?*
Are you involved or serving in ministry at Canyon Hills?*

YESNO
Which ones?*
Do you attend a small group or Life Group?*

YESNO
Do you believe in God?*

YesNoUncertain
Are you saved?*

YesNoNot sure what you mean
Do you pray to God?*

NeverRarelyOccasionallyOften
Do you read your Bible?*

NeverRarelyOccasionallyOften
Do you have regular family devotions?*

YesNo
Explain any recent changes in your spiritual life:
PERSONALITY INFORMATION
What do you think counseling is all about? *
Have you every had any psychotherapy or counseling before?*

YesNo
If yes, list counselor or therapist and dates you were in counseling:*
What was the outcome?*
What kind of involvement do you think a counselor should have in your life?*
CHECK ANY OF THE FOLLOWING WORDS WHICH BEST DESCRIBE YOU NOW:*

ActiveAmbitiousSelf-confidentPersistentNervousHardworkingImpatientImplusiveCalmMoodyOften-blueExcitableImaginativeSeriousEasy-goingShyGood naturedIntrovertExtrovertLikeableLeaderQuietHard-boiledSubmissiveLonelySelf-ConsciousSensitive
Have you ever felt like people were watching you?*

YesNo
Do you ever have difficulty distinguishing faces?*

YesNo
Do colors ever seem too bright?*

YesNo
Do colors ever seem too dull?*

YesNo
Are you sometimes unable to judge distance?*

YesNo
Have you ever had hallucinations?*

YesNo
Are you afraid of being in a car?*

YesNo
Is your hearing exceptionally good?*

YesNo
Do you have problems sleeping?*

YesNo
MARRIAGE AND FAMILY INFORMATION
Name of Spouse*

First NameLast Name
Spouse's Phone Number*
Please enter a valid phone number.
Spouse's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse's Occupation*
Spouse's Age*
Spouse's Education (in years)*
Spiritual Background of Spouse*
Is your Spouse saved?*

YesNo
Is your Spouse willing to come to counseling?*

YesNo
Have you ever been separated?*

YesNo
If yes, when? *
Date of marriage*
Your ages when married *
(ex: Husband 27, Wife 24)
How long did you know your Spouse before marriage? *
Length of steady dating of Spouse before marriage*
Length of engagement*
Give brief information about any previous marriages: *
INFORMATION ABOUT CHILDREN

If you were raised by anyone other than your own parents, briefly explain*
Older Brothers
Older Sisters
Younger Brothers
Younger Sisters
1. Describe why you are seeking help*
2. What have you done to deal with the problem?*
3. What can we do? What are your expectations in coming here?*
4. As you see yourself, what kind of person are you? Describe yourself *
5. What, if anything, do you fear?*
6. Is there any other information we should know?*
I, undersigned, give permission for counseling to proceed:
Signature*

Clear
Date*

MonthDayYear
Date
Parent's signature (if counselee is under 18 years of age)

Clear
Date

MonthDayYear
Date

BIBLICAL COUNSELING POLICY
Sound biblical and compassionate shepherd care are some of the blessings God has given his people in the person of pastors and teachers. We thank God with you that these resources are available as part of the ministry of Canyon Hills Community Church.

The biblical counsel you may receive is provided free of charge, except for the occasional nominal material costs, as an outreach ministry of Canyon Hills Community Church. The counsel is pastoral in nature, intended to provide you with sound biblical instruction and application to the issues of life. The counsel you receive is not intended to be professional mental health care or legal counsel. The counselor you speak with has not received specialized training in medicine, psychology, psychiatry, or law.

Canyon Hills Community Church will honor the principle of disclosure of information only on a “need-to-know” basis. It is the policy of Canyon Hills Community Church to report to appropriate persons and legal authorities: evidence of child abuse, evidence of elder or dependent adult abuse, threat of physical harm to another, threat of self-inflicted physical harm, and information which poses a threat of harm to the congregation and/or ministry of Canyon Hills Community Church.

At Canyon Hills Community Church, we are continually training others to be effective biblical counselors. Part of the training includes the opportunity to observe another counselor in actual counseling sessions. Because of this ministry model we ask that you agree to allow a person or couple who is in training to sit in on your counseling sessions for the purpose of prayer, training and observations.

In your request for biblical care counseling, Canyon Hills Community Church and you agree that any dispute arising out of the care relationship between you and Canyon Hills Community Church and any employee, agent, trainee or volunteer of Canyon Hills Community Church, the exclusive forum for resolving the dispute shall be the mediation and conciliation, and if necessary, arbitration services of a mutually agreed upon Christian mediator/arbitrator. Any resulting arbitration is mutually agreed to be binding on all parties. I have read, understood and agree to be bound by the above stated policies of Canyon Hills Community Church. In addition, I authorize release of information accordingly.
Signature*

Clear
Date*

MonthDayYear
Date
Parent's Signature (if counselee is under 18 years of age)

Clear
Date

MonthDayYear
Date

COUNSELING AGREEMENT
I understand that my counselor is counseling from the Word of God and that no outside resources (specifically psychological input) shall be used during any of the counseling sessions. I understand that my counselor is not certified by the state, rather is held to the Word of God and the standards that come from within the Bible.

In addition to this, I understand that my counselor will be opposed to any outside counseling that I might be involved in. I will stop counseling with anyone else and allow my counselor to be the only one to counsel me. I understand that if I have more counselors than one, that I am putting myself at risk for confusion, which will only add to my problems.

I will be required to go to church once a weekend during counseling. This is to allow for further counseling from the Word of God. If I fail to go to church one weekend, counseling will be suspended for that week and that week only. I understand that if I am too busy to spend one hour of my time with God on Sunday morning or Sunday night, then I am too busy to spend an hour of my time in counseling with my counselor.

In addition to this, I will be on time for all counseling appointments. I understand that my counselor will only wait for ten minutes after my scheduled counseling appointment before he/she leaves. Each time we meet, I understand that we will meet for one hour. I will honor and respect his/her time and call to inform him/her if I am going to be late or if I need to reschedule and I will not come to him/her with counseling issues apart from the time that I have scheduled with him/her. I am aware that if I miss two appointments without having called to inform him/her of my situation that he/she will discontinue his/her counseling services with me.

I will be given homework each and every week of counseling and I agree to complete all of the homework given to me before I come to the counseling session. I realize that only through the help and guidance of the Holy Spirit mixed with my own personal involvement can I change into the person who can glorify God. If I fail to do the homework assigned to me, I will have a valid reason for why I was not able to complete the homework. In addition, if I go three weeks without doing my homework, my counselor will understand that I do not want to change and he/she will discontinue counseling until the point in times that I am willing to change.

Finally, I believe that God can change me and make me into the person that He wants me to be through having the Holy Spirit in my life and obeying God’s Word.

I have read and agree to counseling under these terms:
Signature*

Clear
Date*

MonthDayYear
Date
Parent's Signature (if counselee is under 18 years of age)

Clear
Date

MonthDayYear
Date
Should be Empty:

	Age	Living	Education	Marital Status	Saved
Name
Name
Name
Name

Personal Data Inventory

HEALTH INFORMATION

CHURCH BACKGROUND

PERSONALITY INFORMATION

MARRIAGE AND FAMILY INFORMATION

INFORMATION ABOUT CHILDREN

I, undersigned, give permission for counseling to proceed:

BIBLICAL COUNSELING POLICY

COUNSELING AGREEMENT